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HomeMy WebLinkAboutGW1--06414_Well Construction - GW1_20231009 WELL CONSTRUCTION RECORD For Internal Use ONLY: This form can be used for single or multiple wells 1.Well Contractor Information: ‘1' i /1 L 14.WATER ZONES- l �/ .I2\ , I `J�V 1 n �. ‘O h FROM TO DESCRIPTION Well Contractor Name )iA Oft rt. 2 0-56 •f= ''1g'" ( ' ft NC Well Contractor Certification Number ` 15.OUTER CASING(for multi-cased wells)OR LINER(if ap liable) • ^ ` , 1 ` FROM TO D THICKNESS MATERIAL ��- {V\�\\\\ r5 Wes." ����l,ny + ( ft. 66 R' b1 Sin. l Rs- pvc, 16.INNER CASING ORLTUBING(geothermal closed-loop) • . ' Company Name FROM TO DIALER THICKNESS MATERIAL 2.Well Construction Permit#: l 001(-I/ 63 ft ft in. List all applicable well construction permits(i.e.Count)State,Variance,etc.) ft. ft. ; in. 3.Well Use(check well use): 17.SCREEN • FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL Water Supply Well: it ft. in. ❑Agricultural ❑Municipal/Public f. ft 'in: OGeothermal(Heating/Cooling Supply) PResidential Water Supply(single) ❑Industrial/Commercial ❑Residential Water Supply(shared) -18.GROUT - .. . . FROM TO MATERIAL • EMPLACEMENT METIIOD&AMOUNT Obligation O ft 2...Cs ft. cAeraniAe C`k.X-- Non-Water Supply Well: ft. ft. OMonitoring ❑Recovery Injection Well: ft ft. i ❑Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK Of applicable) .- FROM TO MATERIAL EMPLACEMENT METHOD ❑Aquifer Storage and Recovery OSalinity Barrier ft ft. ❑Aquifer Test ❑StormwaterDrainage ft. ft. ' ❑Experimental Technology OSubsidence Control 20.DRILLING LOG(attach additional skeetsif necessary) ' OGeothermal(Closed Loop) OTracer FROM ' TO DESCRIPTION(color.hardness,soil/rock type,grain size,etc.) OGeothermal(Heating/Cooling Return) 1 ❑Other(explain under#21 Remarks) () f• ID ft r! Clas,) °I I-/ 12 3 I C> ft 2 C) ft i,-c.c 6c c r. ci 4.Date Weil(s)Completed: 'Z.b it 5 o ft loos 0 5hatat r o(,L 5.Well Location: .S-D ft 4 i 5O It 1)1 S I Facility/Owner Name Facility 1D#(if applicable) f. ft. 11'2c Cr-A-x+rt-..) 142‘4. ft ft OCT 0 5 Z023 Physical Address,City,and Zip 21.REMARKS ! �;„ �" ;••_ i l c�lcnbu� t t :i i County Parcel Identification No.(PIN) 5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: (if woll livid,ono lnt/loag is sufficient) CA 1 3S,21%6 I N '80 .5y1 bQ w 2 3 Signature Certified Well Contactor 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 15A NCAC 02C.0200 Well Construction Standards and that a 7.Is this a repair to an existing well: ❑Yes or iMo copy of this record has been provided to the well owner. If this is a repair,JIB out known well construction information and explain the nature of the .Site diagram or additional well details: repair under#21 remarks section or on the back of this form. ( 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 24.Submittal Instructions: submit one form. -1 S 9.Total well 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-3Qa 200'and 2©100) construction to the following: . 10.Static water level below top of casing: SS r (ft.) Division of Water Quality,Information Processing Unit, If water level is above casing,use"+' l 1617 Mail.Service Center,Raleigh,NC 27699-1617 11.Borehole diameter: IV I e (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 12.Well construction method: Ilttr T'CYO A v"--9 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 ServicIe� Center,Raleigh,NC 27699-1636 Method of test: ik\tr 24c.For Water Supply&Geothermal Wells: In addition to sending the form to 13a.Yield(gpm) 5 the address(es) above, also submit one copy of this form within 30 days of i_1.i f e completion of well construction to the county health department of the county 13b.Disinfection type: i'T Amount where constructed. Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013