_Well Construction - GW1_20230320 (9)

WELL UUNSIRUC ION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information.
14.WATER ZONES -
_ fv(_ll.Jt J7 �l/J �'C�(/ �lt ��y' FROM TO DESCRIPTION
Well Contractor Name rt ft. l
ft. ft.
NC Well Contractor Certification Number .15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM 1 TO DIAMETER THICKNESS MATERIAL
• / 1 J l G[L�/'S �P 111% s!J n GZ �'°'C ft. J fG in. �.
Company Name 16.INNER CASING OR TUBING mother at closed=loo
2.Well Construction Permit#: S FROM ft, TO ft. DL4NETER tm THICKNESS 1ATERIAL
List all applicable well construction permits(i.e.County,State.Variance,etc.)
fL ft. in.
3.Well Use(checkwell use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER I SLOTSIZE THICKNESS MATERIAL
❑A cultural ft. ft. in.
� ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) elresidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) .18.GROUT
❑Im ation
FROM TO MATERIAL EMPLACEMENT METHOD&AMMOLNT
rt. ft.
Non-Water Supply Well: 07 e Ct/Coo C/
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK(if a licabie) =-
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. To I MATERIAL EMPLACENIENT METHOD❑Aquifer•Test ❑Stormwater Drainage rt.
❑Experimental Technology ❑Subsidence Control ft. ft.
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiltrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) fL ft. `
ft. ft.
4.Date Well(s)Completed: ,` —7 e)n
ft. f ft.
5.Well Location: ft. ft
•yam
�l�S ft. rt.
Facili i wner Name Facility ID#(if applicable) fL ft.
mot'D1' J ft. ft. i• '7=.., ice`.
f.IItysii'caI Add s City,and Zip 21.REMARK';-'
MAR 2 0 ?021
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: ;�t,�``
(if??well field,one la� lllon_g is sufficient) l /
JS 9 f�J C�JL� N 50 o (0��3
Signature of Certified Well Contractor ate
6.Is(are)the well(s): ermanent or ❑Temporary By signing this form:.I hereby certifi,,that the wells)ivas(were)constructed in accordance
�_
with 1SA 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 Pffol copy ofthis record has been provided to the well owner.
If ilds is a repair;fill out known well construction information and explain the nature of the
repair-under#21 remark section or on the back of this form. 23.Site diagram or additional well details:
J You may use the back of this page to provide additional well site details or well
8.Number of`yells constructed: L construction details. You may also attach additional pages if necessary.
For natltiple itifection or non-water supply wells ONLY with the same construction,you can
submit one form. ) �+ 24.Submittal Instructions:
9.Total well depth below land surface: l t/ M.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifeli ferent(example-3Q200'and 2 a 100� construction to the following:
r 10.Static water level below top of casing: 30 (ft-) Division of Water Quality,Information Processing Unit,
1f Crater level is above casing.use ,+" a 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: V / 'S (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
R�
12.Well construction method: /y 4/ f/ 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: /7 / �" 24c.For Water Sunaly&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.
Fonn GW-1 North Carolina Denariment of F.nvimnment and Nat--Rrmuroac—r)Ivicinn nfw­.,0 Ii—