GW1--03625_Well Construction - GW1_20230526

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1Well Contractor In formation:
ATER ZONES-.WeF 6�yL C RO1�j / O DESCRIPTION
Well
,Coontmc�torNa a ft. ft / 12 /
,/S"
NC Well Contractor Certification Number IS.OUTER CASING for multi-cased wells OR LINER if 80 liable -
l g.� FROM[ TO DIAMETER THHCKNESS MATERIAL
fL in. '` JCS vC
Company Name 16.INNER CASING OR TUBING eothermal cioseddoo
FROM TO DIAMETER I TRICKINESS I MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well consiniction pernirts(I.e.Count}:State,Variance,etc.) in
3.Well Use(check well use): %17.SCREEN -
F01
terSupplyWell: FROgMricultural ❑MunicipaUPublic M TO DIAMETER SLOTSIZE THICKNESS MATERIAL
it. % in.
eothermal(Heating/CoolingSupply) Weidential Water Supply(single) it ft in.
ndustrial/Commercial ❑Residential Water Supply(shared) -18•GROUT .
❑hriti0II ft. ILNT
FROM! TO MATERIAL EMPLACEME METHOD&AMOUNT
Non-Water Supply Well: ft. ft
❑Monitoring ❑Recovery
Injection Well: ft• [t•
❑Aquifer Recharge ❑Gtnundwatcr Remediation 19.SAND/GRAVEL PACK(if t livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENTMIETHOD
ft. ft
❑Aquifer Test ❑Stormwater Drainage ft. %
❑Experimental Technology ❑Subsidence Control
❑Geothermal Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets ifnecessa
( p) FROM TO DESCRiMON color,hardness,sollfrock type rain stze,etc.)
❑Geothermal(Heating(Cooling Return) ❑Other(explain under#21 Remarks) ft. 62 0 ft p c4 Zer_l
4.Date Well(s)Completed: d--3 D ft. D�tt >r y(an
5. ell Location: A On
r
it. ft.M(w -
acilitCy,/OwnerName ��/FFa,,cilityI,D#1(lifapplicable) � ft.
v /i cr-e / L Ann"6�-u..//(13 1(5 ft. ft.
Ph st al Address,City,annd Zip 1
l� 21.REMARKS
CountyLWO
Parcel Identification No.(PIN) Int•.,�:��^n iar�:.7svP:.� �rzt
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: `
(ifwell field,one lat/long is sufficient) 22.Certification:
.950 5- 3oS1VN 800 q/ W �
gi&affrAfCe ed Well Contractor Date
6.Is(are)the well(s): ermanent or ❑Temporary By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENo copy ofthis record has been provided to the well owner.
If this is a repair fill out iitomi well construction information and explain the nature of the
repair under 921 remarks section or on the back of thisform. 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: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,yort can
submit oneform. 24.Submittal Instructions:
9.Total well depth below land surface: D (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple ivells list all depths if different(example-3@200-and 2Q100) construction to the following:
10.Static water level below top of casing: (ft) Division of Water Quality,Information Processing Unit,
ifwater level is above casing,use"/+"/ 1617 Mail Service Center,Raleigh,NC 27699-1617
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: 2?4 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 / r 24c.For Water Supply&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: 3 tr n 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