_Well Construction - GW1_20230320 (12)

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
I -( t 14.WATER ZONES
NcLoL rYl�l L Lis { L u 1;� FROM TO DESCRIPTION
Well Contractor Name 2-O fL I _ J'`q't.
NC Well Contactor Certification Number 15.OUTER CASING for multi cased wells)OR LINER(if a licablc
. r l 1 �(-,t I'L -� l� FROM ft. TO ft. TER in. THICKNESS MATERIAL
t 2S- W C
Company Name 16.INNER CASING OR TUBING eothermal clowd-loon)
/^
1-7FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: co ft. It. in.
List all applicable well consbttctiot pet7nits(i.e.County.State,Variance,etc.)
ft: ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Coolin Supply) ❑Residential Water Supply IL ft. in.
� g/ g PP Y) pp y(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18'GROUT..
❑irrigation
FROM TO MATERIAL EMPLACEMENT METHOD&A OL NT
tt. ft.
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK(if a licable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM tr. ft.To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. rt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG atMeb additional sheets if necessary)
❑Geothettnal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sallfrock e,gmin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I -C> ft. Ll® fL T_e C1
ft. ft.
4.Date Well(s)Completed: 2� �`^� n 5 Ia
tt I-M), W e Ia
5.Well Location:
�1 ft. N
Fa
cili
ty/
Owner Name Facility ID#(ifapplicable) fL fL
Physical Address,City,and Zip
I p 21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22
(ifwell field,one latlong is sufficient) cation:
Certification:
5(z`N � �2-� s�-W U A (�11�/AA, 3.3-an�_�
Signature of Certified Well Contractor Date
6.Is(are)the well(s): �Qermanent or ❑Temporary By signing this Jortn,i herebv certijy that the well(s)ivas(were)constructed in accordance
Itplain
with 15A NCAC 02C.0100 0•15A NCAC 02C.0200 ifell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes orNo copy ofthis record has beenprovided to the well owner.
If this is a repair,fill out known well construction information the nature of the
repair under ft21 remarks section or on the back ofthisJorm. 23.Site diagram or additional well details:
r You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: I construction details. You may also attach additional pages if necessary.
For multiple byection or non-water supply wells ONLY with the same construction,you can
submit one fornn. 24.Submittal Instructions:
9.Total well depth below land surface: 0 / _(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(aranhple-3Q200'and72@100� construction to the following:
r 10.Static water level below top of asing: V (ft,) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"'" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Iniection Wells: Tn addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: �© i� construction to the following:
(i.e.auger,rotary,cable,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: tr 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: IAT14__ Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina nenartment of Fnvimnmrnt nnl Nnniml Rocrn,rrnc-ntv:c;nn nrwot, n„arin.