_Well Construction - GW1_20230320 (19)

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
M `;S /�O►� P1 �GG��O IY 14.WATER ZONES -
la J FROM TO DESCRIPTION
Well Contractor Name 00 ft ft.
c O` 9
NC Well Contractor Certification Number 15.OUTER CASING for multi cased hells OR LINER if a l cable
FROM TO DIAhtE R THIC2ESS MATERIAL
ft. ft. / 1 />f in. . I �•
Company Name 16.INNER CASING OR TUBING geothermal closed'loci
FROM TO I DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: ` w It. ft. I in.
List all applicable well cmutrvtctioll penuits C.c.County.State,Variance,etc.) fL IL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DiAMETER SLOTSIZE THICKNESS I MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) .18.GROUT.
FROM TO MATERIAL EMPLACE11fENT METHOD&AMOLNT
❑Irrigation O ft. 2 ft O
Non-Water Supply Well: bemArn;
ft.❑Monitoring ❑Recovery ft.
Injection Well: IL ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
TO
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiltrock type,grain sl:e,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) a• fL O ft. a
370 v
4.Date Wells)Completed: ft. -Z ft,S-Z fr ft.
5.Well Location: 66 ft. 6 Q fL
ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) fL ft'
^1, t �T
Rkc 'Cl y fL ft:
Physical Address,City,and Zip J 21.REMARKS
MAN 2 0 2023
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22•
(ifwelll�lppfield,one la�t/long is sufficient) �P Certification:
N ' ®� ���b�� W Gt�G'LG i`�%G�!/✓vf/l Z `Z�-L�
Signature of Certified Well Contractor Date
6.Is(are)the well(s):�7Permanent or ❑Temporary
By signing this ja•nh,!hereby certify that the t+=el!(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or And o copy ofthis record has been provided to the well owner.
Ifthis is a repair,fill out known well construction informationplain the nature ofthe
repair ender#21 remarks 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'velI
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For nu hiple injection or non-water supply Alls ONLY with the same construction.you can
submit oneform. / t 24.Submittal Instructions:
/
9.Total well depth below land surface: �'/6 v (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferew(example-3@200'and 2Q1001 construction to the following:
r 10.Static water level below top of casing: 5O (ft.) Division of Water Quality,Information Processing Unit,
Iftvaler level is above casing,use„+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1 I (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
L- above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ��� �l 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: �1 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 Method of test: 24c.For Water Supply&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: �j completion of well construction,to the county health department of the county
where constructed.
Fomt GW-1 North Camlina Denarmrent of Rnvirnnmrnt nnrl Nanim]Rr trrvc-nmcinn nfwar.,r n..u+in,