GW1--03637_Well Construction - GW1_20230526

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This forin can be used for single or multiple wells
1.Well Contractor Information::
Je FFre�• t:_ 'e}� // I I , ) �f"/� 14,1VATER ZONES.- . I `
FROM TO I DESCRIPTION
Well Contmetor-N e ft lL L' �
�(U 02 ,, ft. ft .J
NC Well Contractor Certification Number IS.OUTER CASING for multi-cased wells OR LINER if a" cable)-
FROM I TO DIAMETER THICKNESS MATERIAL
L, I'Y)ic//r s tyel/ �i':Clr`yl G'r+/C / st n ia. 1A5 1 Pa
Company Name 16.INNER CASING OR TUBING 'cothennal closed-loop)
c �l1 Ll �1/� q p FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: i7 oU`o�" R �7�4 O ft. ft in.
List all applicable well constriction permits(i.e.County,State,Variance,etc.) ft ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER I SLOTSIZE THICWNESS I MATERIAL
❑Agricultural ❑MunicipaUPublic 0 ft ft in.
❑Geothermal(Heating/Cooling Supply) Ukesidential Water Supply(single) ft it in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT .
Oftrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft < u��
Non-Water Supply Well: ft Q &tr. ft
❑Monitoring ❑Recovery
Injection Well: ft fL
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACKOfapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL I EMPLAC&MENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soilfrock tne.grain size,etc.)
❑Geothermal(Heating(Cooling Return) ")❑�0tther(explain under#21 Remarks) ® ft ft .( C L�f /
4.Date Well(s)Completed: -3 . =:f 44
Al ft a� ;6&
5.Well Location: ft ft
1--h1-ar)J-0n % ft
Facility/Owner Name Facility ID#(if applicable) - -
it ft
e?O gS w/n C/ ft ft
Physical Address,City,and Zip MAY 2Zl.REMARKS O 2
Ll rnv oI n 3�ays
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification:
(ifwell field,one Nt/long is sufficient)
-onis/ N _ a1'R✓3S• [onS l
of ified Well Contractor Date
6.Is(are)the well(s): 'ermanent or ❑Temporary By signing this form,l hereby certify that the ivell(s)was(were)constructed in accordance
ivith 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 81Vo copy of this record has been provided to the well owner.
if dds is a repair,fill out known well construction information and exploit the nature of the
repair under#21 remarks section or on die 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 injection or non-water supp4,wells ONLY with the same construction,you can
submit ate form. 24.Submittal Instructions:
9.Total well depth below land surface: C76 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For nrulliple wells list all depths if different(erample-3Q200'and 2@ 100) construction to the following:
10.Static water level below top of casing: 12 0 (M) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Marl Service Center,Raleigh,NC 276994617
11.Borehole diameter: / (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
LL above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 744 r y construction to the following:
(i.e.auger,rotary,cable,direct push,eta) Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) nVS Method of test: r 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: �r / Amount• i completion of well construction Ito 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