_Well Construction - GW1_20230320 (15)

WELL ULPINSTKU C i 10A RECORD For Internal Use ONLY:
This form can be used for single oi•multiple}yells
1.Well Contractor Information:
/� / .14.WATER'ZONES-
4e-1 ^n ��n / ��lC�/��i c/�'�r• FROM TO DESCRIPTION
Well Contractor Name ft. ft. o
fL
NC Well Contractor Certification Number 15.OUTERCASING.for• idti-casWivellsORLINERdalicuble';:::';"-'
�j FROM TO DIAMETER THIC&NESS MATERIAL
i I• ►GLl/i�5 Well
22r L��r/!t� L/U� �" ft. ¢ ft. I & ' in. ,a J01/C,
Company Name 16.INNEWCASING OR-TUBING 'cothe' al clokd=loo`
FROM I TO DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit#: fa % in.
List all applicable well constntctionpennits ri.e.County.State,variance,etc.) ft ft. in.
3.Well Use(check well nse): 17.SCREEN:
Water Supply Well: FROM To DIAMETER I SLOT SIZE THICKNESS I MATERIAL
kAgricultural t ❑MunicipaUPublic ft ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT'..
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑ t ft a O R' �en14»nt' OCt�e
Non-Water Supply Well: it. ft:
❑Monitoring ❑Recovery
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL:PACK ufa 'ticable ---
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control f
20.DRILLING LOG attach:additionalsheets ifnecesso
❑Geothermal(Closed.Loop) ❑Tracer FROM I TO DESCRIPTION(color,hardness,so Wrack ce,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) R aft G cc t �r�r.G
fL l)tt. /c�c� �D r✓�S
4.Date Well(s)Completed: Jot ' d 3 ^ 2 9, t1. ft Red OG
kWeRLocation: ft It
oC/l Cu G�
ft. ft.
Facility/Own13 ame 0 Facility ID#(ifappiicable)
� ft ft.
1( R e sc-col 1, ft. ft.
Physical Address,City,and Zip
�,/� �/� 21.REIIA IRI{S Y 1,1 lJ' + �.
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long issssufficient)'356, 17
Gy— `
Signature of Certified Well Contractor Date
6.Is(are)the well(s):Xermanent or ❑Temporary By sighing this form,I hereby certify that the well(s)was(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 j1iZ[No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
p 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,),or(can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: boo (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd�erent(example-3Q200-'sand 2Q100) construction to the following:
1/10.Static water level below top of casing: Q (ft.) Division of Water Quality,Information Processing Unit,
v If water level is above casing,use""+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: / (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
�©7�ar above, also submit a copy of'this form within 30 days of completion of well
12.Well construction method: y 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 e Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2— Method of test: 24c.For Water StmDly&Geothermal Wells: In addition to sending the form to
Amount:/ 7 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: trt / /,Ditll 7�S completion of well construction Ito the county health department of the county
1i�
o where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013