GW1--03684_Well Construction - GW1_20230530

WELL CONSTRUCTION RECORD For Irate- A Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES-.c UcA p j �0� FRO I I
TO DESCRIPTION
Well Contractor Name
Q
R.
NC Well Contractor Certification Number \�J / 15.OUTER CASING for multi-cased wells ORI.INER rf n licable
FROM T5 b R. /_ in. 112T" MATERIAL
le, C
Company Name 1 16.INNER CASING OR TUBING eothermal closed-loop)
V
2.Well Construction Permit#: 2 FROM 2 _��Z fL TO DIAMETER ft. in. THICKNESS INUT+RUL
List all applicable ivell construction penults(.e.County.State,Variance,etc.) in
3.Well Use(checkwell use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft.
❑Agricultural ❑MunicipttUPublic fL in.
OGeothermal eatin Coolin Supply) Supply(single) ft: ft. in.
(H g/ g pp y) Residential Water Su 1 sm le
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑llrl atiOII FROM TO MATERIAL ` EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ZC7
❑Monitoring ❑Recovery ft. fL
Injection Well: fL IL
❑Aquifer Recharge ❑GroundwaterR ediation 19.SAND/GRAVELPACK(ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL LMPLACE�fENT METHOD
fL ft
❑Aquifer Test ❑StormwaterDrainage rL ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG nttach additional sheets lfnecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sollfrotfvtype rain size,eta.)
❑Geothermal(Heating(Coolin Return) ❑Other(explain under#21 Remarks) ft. 6 ft. � � so' % 1
4.Date Well(s)Completed: 2 3 �� rt ��rr ` G nA
r` 2 cut �
5.Well Location: ft. It.
Facility/Owner Name Facility ID#(if applicable)
S6, rL m
Y �
fr. fL
Physical Address�City,and Zip 21.REMARKS
UN1\C>1 02 -1Rq-01-A 1 rn ray• .5.,i,:
County Parcel Identification NO.(PIN) /
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one latilong is sufficient)
35,ar3G SS N 5 116
Signature ofCertified Well Contactor Date
6.Is(are)the well(s): 01ermanent or ❑Temporary By signing this fomi,I hereby certify that the ivell fs)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC OZC.0200 Well Cotutnictiwr Standards and that a
7.Is this a repair to an existing well: ❑Yes or INNo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature ofthe
repair under#21 remark section or on lire 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 supply wells ONLYivith the same construction,),art can
submit one form. P 24.Submittal Instructions:
9.Total well depth below land surface: 200 (ft.) . 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths 1fdifferent(example-3Q200'and 2©100D construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Quality,Information Processing Unit,
#'water level is above casing.use tt 1617 Mail Service Center,Raleigh,NC 276994617
�J (11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
l above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: a .`�'� 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 Supply&Geotheemal 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: ^1 Amount: �✓1 completion of well construction'to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnviroament and Natural Resources-Division of Water Quality Revised Jan.2013