GW1-2023-02355_Well Construction - GW1_20230331

WELL tCONSTRUCTION RECORD D Fbr Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
ATER'ZONES
FROM O . DESCRIPTION
Jell Contractor Name ft. ft. a © 7 J
D 3 ft. fL
NC Well Contractor Certification Number 15.OUTER CASING foe"�uiti-cased iMts OR LINER da 'Gable '
�}� �,y� t FROM TO DIAMETER THICKNESS MATERIAL
- L• //t 'd L a"S &fj e l j'/t %�'1 aL � ft. / ft. in. 4 4;1_
Company Name 9p, .16.INNEWCASING OR=TUBING.' ¢otheriaal clowd-loo' `
i FROM-� TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ��` 11/< It. ft. in.
List all applicable ivell construction permits(r.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 ❑Municipal/Public fc. f in.
❑Geothermal(Heating/Cooling Coolin Supply) �dential Water Supply(single) ft ft. in.
� t;/ g PP Y) est PP Y(• S )
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:.GROUT `r:•:`
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation it
Non-Water Supply Well: �/17�©n
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
[]Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a ilicable -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft, ft TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING1OG attach.additional'sheetsifnecessa
❑Geothermal(Closed Loop) OTracer FROM To DESCRIPTION(color,hardness,sollfrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) fL- Q f'-
eL a f
4.Date Well(s)Completed: :
ft 0 t. 4;m es L,e
Well Location:' ft fL _
ft. ft
Facility/O erName y
Facility ID#(ifapplicable) ft. fL
q 50 14'0-A m ems®ws `/?, ft. ft. - -
Physical Address,City,and Zip 21.REMARKS
c�y�rI-4 s L;V-1 3 "
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification:
(if well field,one lat/long is sufficient)
3.51.3 a g"*25 N 20o 572 iY W 21 3 -16 a3
Signature ofCenified Well Contractor Date
6.Is(are)the well(s): Ffermanent or ❑Temporary By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
O'erwith 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 ERN0o copy of this record has been provided to the ivell owner.
If this is a repair,fill out knoiva well construction h formation and erplahu the nature of the
repair under#21 remarks section or on the 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
r 8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection 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: 30 tO (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths hf different(erample-3Q2000'and 2Qa 100) construction to the following:
10.Static water level below top of casing: C�D (ft.) Division of Water Quality,Information Processing Unit,
r If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
l 11.Borehole diameter: �� (in.) 24b.For Infection 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: 7�D 7<�t►' y construction to the following:
",e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
.3.FOR WATER SUPPLY WELLS ONLY: p 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ! _1 Method of test: �/ r 24c.For Water SunvIv&Geothermal Wells: in addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
s completion of well construction to the county health department of the county
13b.Disinfection type: t h Amount: Or 1� where constructed.
I
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Wa I ter Quality Revised Jan.2013