GW1-2023-02320_Well Construction - GW1_20230331

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This fibrin can be used for single or multiple wells
1.Well Contractor Information:
_ l4.WATER'ZONES.:
��eL •� ye115/ el_l reV rime-/1 P,-" FR—om TO DESCRIPTION
'Yell Contractor Name ft ft. v
ft %
NC Well Contractor Certification Number 15.OUTER CASING-for multi-etised-cvelis OR LINER if a licablc
FROM TO DIAMETER THICKNESS MATFRUL
w&// ��,°��;h� 2ti� ft s� tt. ,, in. ,,� Ale—
Company Name :16.INNER'CASINGOR-TUBING eothertnal.closed-loo' ': 't.
�! FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#.• J ft. rt
List all applicable well consintction permits(i.e.Countyy.State,Variance,etc.) ft in.
3.Well Use(check well use):
"17:SCREEN..,':........:.: .:... .. .... . :.. :. ..
Water Supply Well: FROM TO DiAMETER SLOTSIZE THICKNESS MATERIAL
[]Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ®'Residential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation - ® ft. Q ft. Wn O ,
Non-Water Supply Well:
it. ft
❑Monitoring ❑Recovery
Injection Well: ft. ft
ClAquifer Recharge ❑Groundwater Remediation '19:SAND/GRAVEL PACK ff u licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft ft TO MATERIAL EMPLACEMENT METHOD
[]Aquifer Test ❑Stormwater Drainage
tt tt.
❑Experimental Technology ❑Subsidence Control
-20.DRILLINGLOG attacti'addifional sheets ifnei&sa
❑Geothermal(Closed Loop) OTraeer FROM TO DESCRIPTION(color,hardness,soiVrock type, rain size etQ)
[]Geothermal(Heating/Cooling Return). ❑Other(explain under#21 Remarks)
4.Date Well(s)Completed: �: ' a� ft. y0 ft.
v tt y %
W i Locati n: ft. ft
���t fL ft
Facility/Owner Name Facility ID#(ifapplicable)
r ft ft
Yl ft ft.
Physical Address,City,and Zip /g 21.REMARKS'.
R Bcs(o ".:::. '.
a war _ 1Vl _ tL
County Parcel Identification No.(PIN)" r ;a •..-,,,-,;,;�.� l�l;;
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(if well field,one lat/long is sufficient) f� Signature o Cerdfied Well Contractor ate
6.Is(are)the well(s): 2P'Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
� with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 If'ell Construction Standards and that a
7.Is this a repair to an existing well: Oyes or 5ffgo copy of this record bas been provided to the well owner.
if this is a repair,jl/l out loo i well consiniction h formation and explain the nature of the
repair under#21 remarks section or on file 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 injection or non-water supply wells ONLY ivith the same construction,you can
submit one form, r� 24.Submittal Instructions:
9.Total well depth below land surface: �_ 0_ 0- (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dii ferent(example-3@266 and 2@100) construction to the following:
10.Static water level below top of casing: 4100- (ft.) Division of Water Quality,Information Processing Unit,
e If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: �� (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a,
J- above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: �D T 1V construction to the following:
—i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
3.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 46 Method of test: /7 0 r 24c.For Water SuDDIv&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 t completion of well,construction to 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
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