Loading...
HomeMy WebLinkAboutGW1--03628_Well Construction - GW1_20230526 WELL CONSTRUCTION RECORD For latemal Use ONLY: This form can be used for single or multiple wells I 1.Well Contractor Information: 14.WATER ZONES ;?E�e 72ecAe/^ / C�LIs�I'j �C�/ /7 FROM, TO DESCRIPTION r^1 Well Contractor game. ft. -ft 1709, a oc t� l it ft. 1 loo, NC Well Contractor Certification Number 15.OUTER CASING for multi--cased iveHs OR LINER(if a cable - FROM TO DIAMETER TMCI4,IFSS MATERIAL V. (—• M,/ Lrs well L/yc it I S • �"- _ 13SI Pec CompanyName 16.INNERCASINGOR-TUBING(acothermalclosedloo ) e � � �D �� FROM TO DIA.rIETER THICIINESS JATERIAL 2.Well Construction Permit#: O % '"• List all applicable well construction penults(.e.County,State,Variance,etc.) IL in. 3.Well Use(checkwell use): 17.SCREEN Supply Well: FROM TO DIAMETER SLOT SIZE THI CKNESS MIATERrAL 7ft ft. in. cultural ❑Municipal/Public ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) R I % in. ❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT FROM I TO MATERIAL EMPLACEMUNT METHOD&AMOUNT ❑lrri ation © ft �it. �C�e>7)4,0 ©e t+recr Non-Water Supply Well: ft. ft. ❑Monitoring ❑Recovery Injection Well: it. [L OAquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK f licable FROM TO MATERIAL E,�IPLACEM'IEN'r METHOD ❑Aquifer Storage and Recovery ❑Salinity Barrier % ft. ❑Aquifer Test ❑StormwaterDrainage M ft. ❑Experimental Technology ❑Subsidence Control 2o.DRILLING LOG attnch additional sheets if necess ❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,bardn solUmek arainsizeere) ❑Geothermal(Heating(Cooling Return) ❑Other(explain under#21 Remarks) ft (� it 1� .1 a� fL ft.4.Date Well(s)Completed: ell L cation, JCr7 IL FL Facility/Owner Name Facility IDtk(ifapplicable) ft. % 'r.-..[.-..� fL ft. 4 �: ..�_..•E 11 aM Ph ,cal Addres,City,and Zip 21. REMARKS 2I V ' 't't r ` A. L NA- 20 County C`VE\i Parcel ldentiHcation No.(PIN) 5b.Latitude and Longitude in de ees/minutes/seconds or decimal degrees: v`e vt � �' � 22.Certification: (irwen neld.one inviona is sumcient) .J 5 o /6-O N L d • lfo 02"7` / Vy O O// ed Well Contractor Date 6.Is(are)the well(s): L�ermanent or ❑Temporary By signing this form,I hereby certify that the ivell(s)was(+vere)constructed In accordance with 15A NCAC 02C.0100 or ISA NCAC 02C.0200,Yell Construction Standards and that a 7.Is this a repair to an eltisti ag well: ❑Yes or IdNo copy ofthis record has been provided to the well otmen Ifthis is a repair,fill out lmoxm well construction information and explain the nature ofthe 23.Site diagram or additional well details: repair under#21 remarks section or out the bats ofthisform 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 injection or non-water supply wells ONLY with the same construction,yorr can 24.Submittal Instructions• submit one form. 9.Total well depth below land surface: /S _(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well For multiple,veils list all depths ifdifferent(&ample-3@200•and 2(@I005 construction to the following: 10.Static water level below top of casing: -;t D (ft:) Division of Water Quality,Information Processing Unit, 1f r+rater Tavel is above casing.use"+"/ 1617 Mail Service Center,Raleigh,NC 27699 1617 11.8orehole diameter: �� (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a 0o 11 above, also submit a copy of this form within 30 days of completion of well 12.Well construction method: /1© rQ! _ construction to the following: (i.e.auger,rotary,cable,direct push,etc.) r_ Division of Water Quality,Underground Injection Control Program,J' 13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 24c.For Water Simply&Geothermal Wells: In addition to sending the form to 13a.Yield(gpm) l Method of test: y� u�/✓ 11 the address(es) above, also submit one copy of this form within 30 days of 13b.Disinfection type: Amount: /��+n !S completion of well construction to the county health department of the county where constructed- Form GW-1 North Carolina Department oflinvironment and Natural Resources—Division of Water Quality Revised Jan.2013