GW1--04730_Well Construction - GW1_20230724

•
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for'single or multiple wells
1.Well Contractor Information:
14:'WATER`•ZONES: .-' E _J;: ;.: :a.
T'e Fi i ev � f v r // 4('/CCn /31 C FROM TO DESCRIPTION
•re11 Contractor Name; !! ft. ft. 110 2 S5
6 o ft. ft. ,,/
NC Well Contractor Certification Number 9S.OUTER-CASING(for:multi=cased:wels)ORLINER(if ail licable): . -
FROM TO DIAMETER THICKNESS MATERIAL
W 4. I1 6q'/,'s we/ V r,'U/, , 1-y c -1-'
! rt. 5t0 ft. 4 /j�in. , !.-s pvc
Company Name 6.INNER CASING OR:TUBING(geothermal closed-loop).=:
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: •I 00 // /3 ? 0! • ft. ft. in.
List all applicable well construction permits(i.e.County.State.Variance,etc.) ft • if, in.
3.Well Use(check well use): •
17.SCREEN
Water Supply Well: FROM .TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural OMunicipal/Public
ft ft. in.
OGeothermal(Heating/Cooling Supply) IiirCsidential Water Supply(single)
0 Industrial/Commercial OResidential Water Supply(shared)
18.GROUT:...: .,':::,: _
FROM TO MATERIAL EMPLACE.11IENT METHOD&AMOUNT
❑Irrigation ft ft. r
Non-Water Supply Well: d 1Jeh��n,i�>° Pd�T
❑Monitoring ❑Recovery it ft.
Injection Well: ft. . ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK(if applicable),<.--: . . . .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM . TO MATERIAL EMPLACEMENT METHOD
rt. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. It.
❑Experimental Technology ❑Subsidence Control
20:DRILLING LOG(attach additional sheets ifnecessary) :'., :::r. ::'::
OGeothermal(Closed Loop) DTtacer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return)e ❑Other(explain under#21 Remarks) 0 it 0 ft- Re a c Ley
tu
4.Date Well(s)Completed: / - 3 - a3 0 rt. s j 0 it. y �-�f e.(1®�6 S h p`/
•
. ty O ft
5 ft. P p,2.
( Well Locatio .,'ti- C 0".
Ll 50 ft LAC G/t Q.
JOh 4 Q C��(� ft rt.
Facility/Owner Name J Facility ID#(if applicable) f -, r E; e
ft. ft. #--. •
d/Sl g OfieF IQ. It. ft.
Physical Address,City,and Zip ,�' A:�L 23
21.REMARKS'`.:. ` .
/fee/'Len beef,- . ,,.. ti��pf>"C �UM.
.
County Parcel Identification No.(PIN) l i`0f30G
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
3 5, 19 1/3 Li N S01 5'7 3/02_ w 7 ...6z- - 3 - 23
a r ofC led Well Contractor Date
6.Is(are)the well(s): egmanent or ❑Temporary By signing this form.I hereby certify that the well(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 I1lNo 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 of the
repair under#2/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 injection or non-water supply wells ONLY with the same construction,you can '
submit one form. 24.Submittal Instructions:
9.Total•rvell depth below land surface: Q/ v® (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2Q100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing.use"+'•/ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: /� (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
:Z.Well construction method: R 0'T1`t r/ construction to the following:
,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
Jr - 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: / the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount l n�5 completion of well construction to the county health department of the county
where constructed.
N. Fnrm GW-1 • North Carolina Department of Environment and Natural Resources-Division of Water Quality • Revised Jan.2013