GW1-2023-02306_Well Construction - GW1_20230331

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
ey /�� 14.WATER`ZONES ;
cbg� U I V 1 GC �/ ' FROM TO DESCRIPTION
"fell Contractor Name ,q 0 ft ?�Ooft.
.2 3� ooft. .ZOrt
NC Well Contractor Certiticatipn Number 1 15:OUTER CASING for tnitif cased wells OR LINER tf a lieable
` �11 \ � l FROM TO DIA,,I R THICKNESS MATERIAL
4- ft. 4Q "- 6 1 B in.
Company Name 16.INNER'CASING ORITUBING 'colhermal closed-loop)_
FROM TO DIAMETER THICKNESS JATERIAL
2.Well Construction Permit#: '12 — 3.6 3 ft. fL in.
List all applicable well constrtction permits(i.e.Count)t State,Variance,etc.) ft fit in.
3.Well Use(check well use):
11 SCREEN'.
Water Supply Well: 7..1%GROUT­
FROMTO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. in.
❑Agricultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) i' residential Water Supply(single) ft. itt.
❑Industrial/Commercial ❑Residential Water Supply(shared) TO MATERIAL EMPLACFAIENTMETHOD AMOUNT
❑Irri ation ft {
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEGPACK(ifa livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM tt TO MATERIAL EMPLACEMENT METHOD
it.
❑Aquifer Test ❑Stormwater Drainage
fit tt
❑Experimental Technology ❑Subsidence Control
20.DRILLING tiOG attach additional sheets iCnecessn '
[]Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,sotUrnck a rain size,etc—)
❑Geothermal(Heating/Cooling Return) ❑Ot er(explain under#21 Remarks) 0rt fit r-�w y,
,ft-
4.Date Well(s)Completed: �• rL f t V A ke
L `700"- ):Ave S`a► �o ,
f Well Location: _ _ fit ft
^� ��t r —
Facility/Owner Name Facility ID#(ifapplicable)
.�{ ^� It. ft.
IQ®L �1V1� r````` l ft ft.
Physical Address,City,antfZip 21. 4
Vmorl ^ZLAC2^-6C6r_ ' .
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: trtrcc,
22.Certification:
(if well field,one lat/long is sufficient)
3y r� 610LI N 9C6, sa Z 1� w -4 t,IK 3 i z 3
Signature of Certified Well Contractor Date
6.Is(are)the well(s):Y."manent or` ❑Temporary by signing this form,I hereby certify that the tvell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 a•15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ) No copy of this record has been provided to the well owner.
If rhts is a repair,fill out/Dorm well construction h formation and explain the nature ofthe
repair under#21 remarks section or on the back of this ornt. 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 injection or non-water supplr wells ONLY with the same construction,you can
submit ore form. �] 64 24.Submittal Instructions:
9.Total well depth below land surface: —1 O 0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erantple-3 rQ200'and 2Q1001 construction to the following:
10.Static water level below top of casing: y (ft) Division of Water Quality,Information Processing Unit,
r If water level Is above casing,use"+" i f 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
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 1?=CA�Ir construction to the following:
e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
3.FOR WATER SUPPLLY7 WELLS ONLY: ` 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) / Method of test: 24c.For Water SunDly&Geothermal Wells: In addition to sending the farm to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 4T Amount: t� ' r"-A-% completion of well construction ti the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013