GW1--03686_Well Construction - GW1_20230530

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
i I - 14.WATER ZONES-. I I
I V I h �� C-t(iI'V i Y'1 S GC,� -Qr) FROM TO DESCRIPTION
Well Contractor Name t 0 ft L fL
-Z cic�'p
NC Well Connector Certification Number 15.OUTER CASING for multi-cased wells OR LINER f a licable -
` ` FROM TO DIA THICKNESSMATERiAL
--
D�- M.
`�, W�.1� ` c� \\ �Cl I ft. ft , in. r v C,
Company Name 16.INNER CASING OR TUBING 'e-othetimal closed-loop)
'-7 V FROM TO DIAMETER IAL,THICKNESS MATER
2.Well Construction Permit& G Z 15 ft. ft in.
List all applicable well consiniction permits(i.e.CountJ•,State,Via lance,etc.) ft ft in.
3.Well Use(check well use): 17.SCREEN .
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ft. ft. in.
❑Agriculhiral ❑Municipal/Public
[]Geothermal(Heating/Cooling Coolin Supply) diResidential Water Supply fL ft. in.
(H S/ g PP Y) PP Y(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL E.VIPLACEN .IENT ETHOD&AMOUNT
Non-Water Supply Well: ft Z
❑ non a ft �en %-�a❑Monitoring ❑Recovery ft. ft
Injection Well: ft M
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK(if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier % ft
❑Aquifer Test ❑StormwaterDrainage ft ft
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attacb additional sheets ifnecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,solarock type.grain si etr-)
❑Geothermal eating/Cooling Return) ❑Other(explain under#21 Remarks) I ft 2 fL C CIC
4.Date Well(s)Completed: t ft ft C I a
0 ft ` f
5.n Well Lo ation:` ` $-oft /(,Cft.
% ft
Facility/Owner Name y/ Facility ID#(ifapplicable) fL fL
T%eAAow`_ _
Physical Address,City,and Zip 21.REMARKS
MAY 11
���n pb 1'-1'� ®3S
County Parcel Identification No.(PIN) lRSGS 'iw^� :'C^;;.:,;• ,-.�;�D;i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:. 22.Certification-
(ifwell field,one laUlong is sufficient) „
35t�1t?,22 N ��t'-( D£ w � � s"
Signature ofCenified Well 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 ISA NCAC 02C.0200 Well Consintcton Standards and that a
7.Is this a repair to an existing well: ❑Yes or IdNo copy of this record has been provided to the ivell owner.
ifthis is a repair fill out known well construction information and arplain the 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
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For nuthiple h1 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: #00 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erantple-3Q200'and 2®1005 construction to the following:
10.Static water level below top of asing:. �d (ft.) Division of Water Quality,Information Processing Unit,
guater level is above casing,use
pp+,,^ l if 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ICJ (in.) 24b.For Infection 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: 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) Q d Method of test: r 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: • t- Amount: l -�j 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