GW1--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