GW1-2022-10359_Well Construction - GW1_20221115

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
FROM
J FROJ9 TO DESCRIPTION
Well Contractor Name, ft. G C ft• y� /�
A0 3 g ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for_multi-cased wells)OR LINER if a 1(eahle
l /� FROM TO DIAMETER THICKNESS HATE L
"11�• ��L.�r�1�� O ft O ft. 16 / in. �2 5' 0 C
Company Name 16.INNER CASING ORTUBING( eothermal closed-loop)
b,Well Construction Permit#: - `p- FROM fL TO ft DIAMETER in, THICKNESS IN
List all applicable hell cvnstntctlon penpits(i.e.Comity.Slate,Variance,etc.) ft ft. in.
3.Well Use(check well use): 17:SCREEN
Water Supply Well! FROM TO DiA.IIETER SLOTSIZE THICKNESS MATERIAL
❑Agticulhlral ❑MttnicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) deesidendal Water Supply(single)
ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM to MATERIAL } EIMPLACEIUENT METHOD&AMOUNT
❑Irrigation 0 rr 6 ft. eh 621/ 6
Non-Water Supply Well: ft. fr.
aga
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM tr. TO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stotmwater Drainage ft. it.
❑>xpetimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,solUrock type.grain slz%etc.)
❑Geothermal(Heating/Cooling Return) )❑Other(explain under#21 Remarks) U fr o ft l)u�N Al
4.Date Well(s)Completed: / ' I- , d ft• bb fr
,. 66 rc a 6o d tr.
5.Well Location:
11
ft. ft.
Facility/Owner Name Facility ID#(if applicable)
I L� f/ D/t i t "I e 0 9 ft. ft. r f
Physical Address,City,and Zip 21.REMARICS t! w
Ufl.,16N c�r�� L-aa 5 L� 1
County Parcel Identification No.(PIN) I f)i`xiir't;&$jj�^I {
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(if well field,one lattlong is sufficient)
� S lure of Certified Well Contractor Date
6.Is(are)the well(s): wrPermanent or ❑Temporary By signing this form.1 hereby term that the rvell(s)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200]Fell Construction Standards and that a
7.is this a repair to an existing well: Oyes or Aio copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature ofthe
repair under#21 remarks section or on the back of this fornr. 23.Site diagram or additional well details:
You may use the back-of this page to provide additional well site details or well
8.Number of`yells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water sapply wells ONLY ivith the same construction,you can
submit one form. 24.Submittal Instructions:
6 n�9.Total'well depth below land surface: V (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200e',and 2Q100� construction to the following:
r 10.Static water level below top of casing: 7 D (ft.) ]Division of Water Quality,Information Processing Unit,
If[rater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
t
11.Borehole diameter: (in.) 24b.For Infection Wells: in addition.to sending the form to the address in 24a
tn above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: J U construction to the following:
(i.e.auge rota • able,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY- 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 1 24c.For Water SuppIv&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount 2 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013