GW1--04771_Well Construction - GW1_20230724

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
�1.Well Contractor`1 Information: / ty�y�. `�
w 1` y / ��"��• `o �,I_ 14.W TO DESCRIPTION
ell Contractor Name- ft. ft.
Le O\- L i ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING.(for rirulti-cased;wells)-OR LINER(if ap'licable)':.
' may/ FROM TO DIAMETER THICKNESS MATEIUAL
f�' L M r / /I cal well d/r/L( }'1 i-i/C ft. ft. in.
--16.INNERCASING OR-TUBING eothermal closed400 '
Company Name {g p)",':':::.,,•_ ,, ..:.., .-
_-„„1 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit# d: • ` . ,."1_5 • 1 ft. I/ 3�tr. /4 in. P�/C
List all applicable well construction permits(Le.CounV.State,Variance,etc.) ft. ft. in.
3.Well Use(check well use):
Water Supply Well: - FROM .TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural OMunicipal/Public
IL ft. in.
❑Geothermal((Heating/Cooling Supply) ❑Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared)" .-.18:GROUT: ..-
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation ft. t, ft
Non-Water Supply Well: `�\ �di< gvrd �Ol�f e�
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
•
❑Aquifer Recharge ❑Groundwater Remediation '19:SAND/GRAVEL.PACK(if applicable). _:i- :' :::::: ::',:.- . :`•:'• '-.:
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. It.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attack additional sheets-ifnecessary)':::..::" :` ==: ' -:
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color.hardness.soil/rock type.grain size,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
R, ft.
4.Date Well(s)Completed: 6'� dd2 " a 3
ft. ft
Well Loca'on�p •
ft. ft.�Jl rt. .
i6,--..
Fa �� t�� �1ity/Owner a Facility ID (if applicable) ft. ft. P • E r-
Oo� 5c,�,�vU� A ft. ft. Li
JUL 2 4 2023
( �
/ Physical Address,,City,'and Zip3CL- 2&LO3 21.REMARI{S I PtlEOfrTi"�Aafl 1 f,. "11oirg URi;
County Parcel Identification No.(PIN) C1.'.1' '
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one laatiloong is sufficient) 17410 p� /
35 o' [v 3 S N 50', � IO W 1Wa).. �•" 'D-3
Signatury d Well Contractor Date
6.Is(are)the well(s): @(Permanent or ❑Temporary By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: 171r4: or ❑No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain die nature of the
repair under i121 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-tvell depth below land surface: (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 2()a 100') 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 Injection 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
---;s2.Well construction method: construction to the following: -
ti e.auger,rotary,cable,direct push,etc.)
`,i % 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&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Amount: )D`a C�2 completion of well construction to the county health department of the county
-�13b.Disinfection type: \\
where constructed.
Fonn GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised)an.2013