GW1--03626_Well Construction - GW1_20230526

WELL CONSTRUCTION RECORD
For Internal Use ONLY: j
This form can be used for single or multiple wells
1.Well Contractor Information:
Te-lF ✓LC / u r + 14.WATER ZONES-
�I // /ey [(/fe r— ,/ 29 rt.-rI P�'I ,c e FROXI TO DESCRIPTION ��ll
Well Contractor Name ft. ft Z/ a S
A
ft. it �
NC Well Contractor Certification Number 15.OUTERCASING for multi-cased wells OR LINER da livable -
FROM TO DIAME THICKNESS MATERIAL
��• /r�u!/i s wed/ Vr;t A4 zrvc ft. 1d / in. F J�s �e
Company Name 16.INNER CASING OR TUBING cothennal closed-loop)
� I FROM I TO I DIAMETER I THIC"ESs I MATERIAL
2.Well Construction Permit#: ft. it. in.
List all applicable well construction pen+tits(i e.Coun),.State,Fmiance,etc.) IL ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Mun+icip&Public ft• ft. in.
❑Geothermal(Heating/Cooling Supply) "O idential Water Supply(single) ft it in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Ohrigation fL fL D
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well: ft ft.
❑Aquifer Recharge ❑GmundwaterRemediation 19.SANDIGRAVEL.PACK(ifapplicable)
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑StormwaterDrainage ft ft
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG nUach additional sheets if-necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION(color,hardness sollfrock type.grain sum,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. Q f A
tft. 0 a l
4.Date Well(s)Completed: 5 o?,r 0�-3 �� ft. ! e Q t
Old IL le a rt La G r
5. ell Location: �` L
e, 3 ' ��� ft. rt. C�
Facility/Owner Name Facility ID#(ifapplicable) ft ft
&156 V e ll by�,Sl "rr- V fl. fL ft. MAY u
Ph ical Address,City,and Zip 21-REMARKS
In;ter ;„i.�n 'r • :, ::�Un,'
County Parcel Identification No.(PIN) v v"a C"''3 OCT
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one latilong is sufficient)
350 b(o5 8 'R N goa '7 d '731 W � 5 2 gn ?3
� u C ed Well Contractor Date
6.Is(are)the well(s): Ir�ermanent or ❑Temporary By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance
with 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 214 copy of this record has been provided to the well owner.
Ifthis is a repair,fill out knomi well construction information and explain the nature of the
repair under#21 remarks section or on the back of thisfirm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple ittifection or non-water supply wells ONLY with the same construction,your can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: . (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@ 1001 construction to the following:
10.Static water level below top of casing: vS (th) Division of Water Quality,Information Processing Unit,
Ifwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: �D (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
rn
1 above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: W.9 / VL r[/ 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 Map Servici Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: / !� 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: 14 / H Amount: al'-') 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