_Well Construction - GW1_20230320 (13)

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
.14.WATER ZONES
1!'� G� b� FROM TO I DESCRIPTION
Well Contractor Name C) ft.
ft. ft.
NC Well Contractor Certification Number � � 15.OUTER CASING forulti-cssed wells)OR LINER air a livable
FFROMTO m Mi T DIAER ES THICKNSI MATERIAL
11. 1 la in. f I�� 'PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER in.
MATERIALZ.Well Construction Permit#: '� 2 2 (r. fr. in.
List all applicable well construction pennilsC.e.County.State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS II MATERIAL
ft.
❑Agricultural ❑MunicipaUPublic ft. in.
( g Supply) Supply(single) ft. ft.
❑Geothermal Hearin Coolin 5u 1 'S1Ae idential Water Su 1 sin le
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation ft. ft. ureot
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if n livable) .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
❑)xperimental Technology ❑Subsidence Control rt. rt.
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION(color,hardness,soli/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1 ft. fL
0 ft.
4.Date Well(s)Completed: ft r ft. 1
S.Well Location: ft. ft U
yi
MAnys ft. ft.
Facility/Owne,r Name Facility ID#(if applicable) -
�� ft. ft -
rt. rc.
Physical Address,City,and Zip
' �, ♦ 21.REMARKS -9-2023
County Parcel Identification No.(PIN)
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one latlong is sufficient)
/� Signature of Certified Well Contractor Date
6.Is(are)the,veIl(s):\Permanent or ❑Temporary By signing this form.1 herebv certify that the well(s)tvas(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C-0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or "Ea< copy of this record has been provided to lire ivell owner.
1f this is a repair,flll out known well construction information and explain the nature of the
repair under#21 remarks section or or the back of this form. 23.Site diagram or additional well details:
You may use tine 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 h jectionn or nor-water supply wells ONLY with the same construction,you can
submit one form. ` 24.Submittal Instructions:
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3Q200'and 2Q1,(101 construction to the following:
e 10.Static water level below top of casing: L4 (ft.) Division of Water Quality,Information Processing Unit,
1f water level is above casing,use/+'i 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: l� (in.) 24b. For Iniection Wells: in 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: f 5 ��`\/ 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: ,r" 24c.For Water Sunnly&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 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Denartment of F.nvirnnment and Matn-1 Rran---ni.k;—of w—n,.aun,