GW1--03636_Well Construction - GW1_20230526

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
i1.Well Contractor Information:
14.WATER ZONES:
`� `1L• GV n �1C�-�.7lJr s FROM TO DESCRIPTION
Well Contractor Name ft. 170ft. i
It. I
NC Well Contractor Certification Number 15.OUTER
CIN 'fa lienble A O
FROM '
DIAMETER THICKNESS MATRRL41.
Y\.•- i V\�1\ 5 �4�9e,\\ r \i:�r� It S f� fG /_ t�In. ., g�J, v
Company Name 16.INNER CASING OR TUBING cothetinal closed-loop)
DIAMETER
Z.Well Construction Permit#:__ 1 0 b �� FROM��q R TO. it. in. THICKNESS MATERIAL,
List all applicable well construction permits(I.e.Count}:State,VmIance,etc.)
ft. it. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
[]Agricultural ❑MunicipaUPublic
ft. R. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in.
❑Industtial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: �12
❑ aon ft. L.) f C b�{r
❑Monitoring ❑Recovery it. fL
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ff a p licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. ft To MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDminage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRII,LBVG LOG attach"additional sheets if-necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION(color,hardness,solUrock tna grain size,etc.)
❑Geothermal(Heating(Cooling Return) ❑Other(explain under#21 Remarks) tR fL a S% re Q1 G S`
4.Date Well(s)Completed: 'Z� Z. a 5 fr 0 ft
5.Well Location: D ft r t
,. Law-sonMoon xr�t-ems' aka' r`--�
Facility/Owner Name Facility ID#(if applicable) ft
Physical Address,City,and Zips 21.REMARKS
�ktt�b i G�1-o32r o"1MAYG2023
County Parcel Identification No-(PIN) llh{fn"t%, w l i�I '�vir'r L!fl
5b.Latitude and Longitude in degrees/minutes/seconds or decimall degrees: ra cat
(ifwell field,one ladlong is sufficient) 22.Certification:W
� �z�03N eh b�
Signature ofCertified Well Contractor Date
6.Is(are)the well(s): wrrmanent or ❑Temporary By signing this form,1 hereby certify that ilia ivell(s)was(were)constructed in accordance
�,,� with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 A'ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 'PH copy of this record has been provided to the well ot+mer.
if dds is a repair,fill out known well construction information and erplaut Bic nature of the
repair under#11 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: construction details. You may also attach additional pages if necessary.
For multiple i 1faction or non-water supply wells ONLYwith the same construction,you can
submit one form. ��7�M,,,,.,, ` 24.Submittal Instructions:
9.Total well depth below land surface:_ 5?M (ft.) 24a. For Ail Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths lfdierent(example-3Q200'and 2@1001 construction to the following:
10.Static water level below top of casing: tz (ft.) Division of Water Quality,Information Processing Unit,
1f water level is above casing,use"+ 1617 Matz Service Center,Raleigh,NC 276994617
11.Borehole diameter: (in.) 24b.For Iniection 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: 140 �/� / 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: qq 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) J'e Method of test: Jr f! 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: Ltt Amount Y 1� completion of well constructions 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