GW1-2022-00337_Well Construction - GW1_20221222

WELL CONSTRUCTION RECORD
This form can be used for'single or multiple wells For Internal Use ONLY:
is We'l ontractor Inform tion:
14.'WAiTER ZONES_: _
FROST TO DESCRIPTION
Well Contractor Name 1 " 9 6 It.
I I �d O
01 b 3 (O ft. ft. VT
NC Well Contractor Certification Number 15.OUTER CASING for mul l•=e iied wells ORLWER d:a licahle {:•':"
1 FROM TO DL METER THICKNESS MA RIAI
L C, n ( o rt. ft.
Company Name 36.INNEWCASING OR-TUBING` cothermal cibsed-trio
(� FROM TO OLU�IETER THIC"ESs NIATERiAL
2.Well Construction Permit#:_ T ft. fr. in.
List all applicable+vell construction pennirs(,.a-Como,.State,Variance,etc.)
It. ft. in.
3.Well Use(check wen use):
Water Supply Well: 17..SCREEN,;
FROM TO DWIETER SLOTSiZE THICKNES S MATERIAL
❑Agricultural ❑Municipal/Public ft• ft. in.
❑Geothermal(Heating/Cooling Supply) ,Residential Water Supply(single) ft• ft. in.
❑Industrial/Commercial ❑Kesidential Water Supply(shared) 18.GROUT
❑1ni ation FROM TO MATERIAL ESIPLACF11fENTS1ETHOD&AS10WiT
Non-Water Supply Well: 0 ft. � ft. (� d P
❑Monitoring ❑Recovery ft. fL
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL:PACK(if a' [icahle)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
ft. �
❑Aquifer Test ❑Stormwater Drainage ft.
❑Experimental Technology ❑Subsidence Control ft. ft. I'
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets ifnecessa
FROM TO DESCRIPTION(color,kardness,soiVrock e, rain size,cta).
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) oft• It. I
i
4-Date Well(s)Completed: I I"� L QZ ft. f4 CS�/v
ft ft
5.W�J1 Location /t
fL
eft 60
Facility/Owner Name ft.
Facility ID#(ifapplicable) t{ )l�l ft. ft.
Physical A�d/d�ress,City,and Zip
a 21,REMARKS
��
96
County ,i I In'l
Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilong is sufficient) 22.Certification:
J�.�t N W L�1L
6.Is(are)the well(s): laYean rment or ❑Temporary Sire of Certified Wellonnnew 1r, Dam '
By signing this farm.I herebv certify that the ivell(s)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 arell Contraction Standards and that a
7.Is this a repair to an existing well: ❑Yes or &W copy of this record has been provided,to the well omier.
Ifthis is a repair,fill out knot-well construction information and explain ilia nature ofthe
repair under#21 realarla section or on the back of this form. 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 wells constructed:_ construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,von can b
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface:_ t 60 (ft•) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3@200'and2@100') construction to the following: I i
10.Static water level below top of casing: C3,5 (ft) Division of Water Quality,Information Processing Unit,
if irater level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
G '
71.Borehole diameter: 24b.For Infection Wells. In addition to sending the form to the address in 24a
+ above, also submit a copy of this iform within 30 days of completion of well
12.Well construction method: i construction to the following:
rotary,
(i.e.auger 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) oC /2., Method of test: I 24c.For Water SuDDiv&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: 1' completion of well construction to the county health department of the county
where constricted.
I;
Form GW-1 North Carolina Department ofEnvironment and Natural Resources—Division of Water 9 uali
iQ ry Revised Jan.2013