GW1--03639_Well Construction - GW1_20230526

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells
1..Well Contra�ce�1 7-" 7+tor Information: J
,!'�FF/ 1 Ip r. 14.WATER ZONES. - 4
� �e�vl� /11� FROM TO DESCRIPTTON
Well Contmctor Name ft. IL
/ (T/D f. ft. fL / .Q112
O
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased Wells OR LINER if a ticable
FROM TO DIAMETER THIC&NESS MATERIAL
f�J ell �r t"L I in cy /t/L I" it. fL ! ir. r f� to I/C
Company Name 16,INNER CASING ,OITUBING eothermal closed-loop)
FROM TO DIAMETER TMCi MESS MATERiAL
2.Well Construction Permit#: ! ` / r fL m in•
List all applicable well construction pennits(i.e County.State,Yarlance,etc.)
fL f in.
3.Well Use(check well use): 17.SCREEN .
Water Supply Well: 7:1
.,5 DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public❑Geothermal eatin Coolin Su 1 ppy(single) -ft. in
(Ii g/ g Supply) t�estdential Water Supply
❑lndustriaYCommercial ❑Residential Water Supply(shared) 18.GROUT .
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. o2('fLCGn' •'
Non-Water Supply Well:
fL fL
❑Monitoring ❑Recovery
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if n licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM tL TO MATERIAL EMPLACEMENT METHOD
lw
❑Aquifer Test ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if-necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiUrock type.grain si etc.)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) 0 ft. 20 fL Lod e(dt I
6 ` 23 fL 5s ft. 1 fle e.✓ki f/ems
4.Date Well(s)Completed: it, ft
5.Well Location: �(
t1. Oft. LG. ro!«itr+
fL fL
Facility/Owner Name Facility 1D#(if applicable)
jSI Wash /?J
rt. ft
Physi I Address City,and Zip 21.REMARKS M0 20231
County ParcelIdentificauonNo. [N) v' ' ' ' =
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(iFwell field,one Iat/lonp is sufficient) Q Q `_ ?
,3..S* 50,5-6 - N SD o -ICJ V®� W Q o�� -� ��� � ?J
/ Si f eti5 ell Contractor Date
6.Is(are)the well(s): ['Permanent 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 o copy of this record has been provided to the ivell owner.
Ifthis is a repair;fill out known well constr•uctiot information and erplafn the nature of the
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
S.Number of wells constructed: ! construction details. You may also attach additional pages if necessary.
For multiple iti ection or non-water supply wells ONLY with the same construction,you can
submit one form. *� 24.Submittal Instructions:
9.Total well depth below land surface: oG (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depllrs ifd fferent(example-3Q200''yand 2Q100) construction to the following:
10.Static water level below top of casing: S © (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
,p 1 above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: !�� "t r t/ 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) / D Method of test: /�'rr 24c.For Water SunDly&Geothermal Wells: In addition to sending the form to
the address(es) above, also submii one copy of this form within 30 days of
13b.Disinfection type: Amount: 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