GW1-2023-02321_Well Construction - GW1_20230331

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information::
"!'l l _/V et �e l/ `�LC cll P 14.WATER'ZONES-.-. :...:: ..:..:.. ..
r FROM TO DESCRIPTION
„-rellCon`tractoIr Name
/ ft. ft. 's :;0401 12 0
oS D�v ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for m4I&cssed;wells OR LINER rf a 'livable
FROM TO DIAMETER THICKNESS MATERIAL
Company Name 16.INNER CASING:OR TUBING eiithermaI closed-loo
FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: ft. ft.
List all applicable well construction permits(1.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) )RGsidential Water Supply(single) n: ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) '18:.GROUT: 5
FROM TO MATERIAL EMPLACEMENT:11ETHOD&AMOUNT
❑Irrigation r
Non-Water Supply Wellc
❑Monitoring ❑Recovery ft, IL
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a livable):!-_
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
IL ft.
❑Aquifer Test ❑StormwaterDrainage fu ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach utlditiorial sheets ifnecessa '
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) O ft- 90 IL
s� D IL 190 ft.
4.Date Wells)Completed:. 37 s/Jn ��� 3 ,.
Well Location: , d� ft.
:y ft. 13 d oil-
ft. ft.
Facility/Ovmer Name Facility ID#(ifapplicable)
fa ft.
�.J lS tl L �D n co r iC ft ft.
Physical Address,City,and Zip t:.
..21.REMARKS,':' .'r I I I 1 C.J.. .
County Parcel Identification No.(PIN)
r,xryr -:iYiY
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(i'fwell field,one lat/long is sufficient)
' mm `' !�
S 602 (�S N O 0 "1 9 / � W ,�fe�C`1� �� 3—15'—A3
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ermanent or ❑Temporary By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
��r will: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 fdi10 copy of dds record has been provided to the ivell 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 the back of Unis 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 hyection 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: y ,0 o (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3 a 200'and 2(3a 100D construction to the following:
10.Static water level below top of casing: J (ft.) Division of Water Quality,Information Processing Unit,
r If water level is above casing,use
//"+^ 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: fo �� (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
12.Well construction method: / ©ka I- construction to the following:
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
/+ 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: /?f / the address(es) above, also submit one copy of this form within 30 days of
z✓ r completion of well construction to the county health department of the county
13b.Disinfection type: Amount: where constructed.
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Form GW-I North Carolina Department offinvironment and Natural Resources—Division of Watdr Quality Revised)an.2013