_Well Construction - GW1_20230320 (61)

WELL CONXTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information.
14.WATER7,ONES
�tCG/r Pr FROM TO DESCRIPTION
Well Contractor Name ft ft. J �?
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased ivells OR LINER if a llcablc
FROM I TO DIAMETER THICKNESS MATERIAL
U. r / /�!!rr� W Q! /✓�/1 Cl i'n /(�C ! ft. in. , /
Company Name 16.INNER CASING(ORTUBING closed4amil
/ Qj FROM TO D1AINIMR THICKNESS JIATERIAI.
2.Well Construction Permit#: 7� R. ft. in.
List all applicable'veil construction penmits(7.e.County,State.Variance,etc.)
ft. ft, in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) R1 residential Water Supply(single) ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18,GROUT
FROM TO MATERIAL EMPLACEIMENT METHOD&AMOUNT
Non-Water Supply Well: V
❑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 fr. ft.To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sollfrock rype,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) d ft. C c 6) ft. Reel f /Q
ft. 80 ft. .. C
4.Date Well � a s)Completed: ..r' 0 � � 3 � ft, ft.
S.Well Location: ' 97/1 ft-
ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft
1113 C-e-da r fr,,-n cA LT ft. ft. n��
Physical Address,City,and Zip q I ( .REMARKS , c -:-;, 1 :'i( >�•'• !"—
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one iat/long is sufficient)
3S•13 l 1/3 N g'1 a $ 'l7 3
W ae4--4 gye
��tt Signature of Certified Well Contractor Date
6.Is(are)the well(s): 215ermanent or ❑Temporary By signing this form,I herebv 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 1�IVo copy ofthis record has been provided to the trell 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 lire 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 ihyection or non-water suppb,wells ONLY with the same constrnetiun,you can
submit oneform. 24.Submittal Instructions:
9.Total well depth below land surface: DO (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3Q200'and 2Q100') construction to the following:
10.Static water level below top of casing: ��C2 (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: lr� �Q' (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: U/ 1l f t./ 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: !t/� 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: O/tn. J' completion of well construction to the county health department of the county
—T— where constructed.
Form GW-1 North Carolina Denarmenr of Rnvirnnmenr and Normal Rican_nivieinn of Urvr..r r)nunin,