GW1--03635_Well Construction - GW1_20230526

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This farm can be used for single or multiple wells
1.Well Contractor Information:
`1 r ]4.WATER ZONES.. I-
�� V'1 i 5 CAJ'tt^ 73'GL� FROM TO I DESCRIPTION
Well Contractor Name d ft. -1
2 0 3q L C10 ft-
NC Well Contractor Certification Number 15.OUTER CASING for multi cased averts OR LINER d e licable
FROM TO D THICIL�IES3 MATIIUAL
Company Name 16.INNER CASING OR.TUBING acothermal elosed4o6
,Ce I FROM TO DIAINSETER I THICKNESS MATERIAL
2.Well Construction Permit#: % ft in.
List all applicable well construction permits(I.e.Como,.State,Variance,etc.) � ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERL%L
❑Agricultural ❑Mumicipal/Public % R. in.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft ft in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT:. =.
❑hri
FROM TO MATERL`` __ EMPLACEMENT. OD&AMO
Non-Water
ater Supply Well: IA
f- -2 0 ft --no '1'C� Dui'❑Monitoring ❑Recovery ft ft
Injection Well: ft fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK tf a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL ENPLACE117ENT METHOD
ft ft
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets ifnecess
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hordness,soWrock c croin eta)
❑Geothermal(Heating(Cooling Return) ❑Other(ex lain under#21 Remarks) IL ft r- j
,'� ft 3 c7 ft- s a+ s 0 P'e-
4.Date Well(s)Completed:
5.Well Location: ft rl(YL
11
. NC It.
ft
Facility/Owner Name Facility ID#(ifapplicable) it % ;: r L,
�%q P.�kA�1 I NQ tr-, R� h,-4r-I e�1VC IL ft � '< : ;d �y y� a
Physical Address,City,pnd Zip 22.REMARKS
County Parcel Identification No.(PIN) " '�I f •�,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
'35 1 16601 N Sot 66-56 `,It ZJ--� A - S 1123
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,I hereby certify that the rvell(s)was(were)constructed in accordance
lvith 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Nell Constntedon Standards and that a
7.Is this a repair to an existing well: ❑Yes or VNo copy of this record has been provided to the ivell owner.
#"this is a repair,fill out disown well construction information and explain rite nature ofthe
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
8.Number of wells constructed: I construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY ivith the same construction,you can
submit one form. ^� 24.Submittal Instructions:
9.Total well depth below land surface: J7-Q (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2Q100 construction to the following.
r
10.Static water level below top of casing: (ft) Division of Water Quality,Information Processing Unit,
If water level Is above casing.use"+" 1 1 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: I (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a -
p above, also submit a copy of this farm within 30 days of completion of well
12.Well construction method: V-'AG 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: 24c.For Water SuDDIv&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 �l'1 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 Ian.2013