GW1--06416_Well Construction - GW1_20231009

WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Informati n: • '
�^ (/.��' I
1i.etv`n �c 1\L �.ACi�.�) 'TqG�«t��
14.WATER ZONES- .FROM TO DESCRIPTION
Well Contractor Name , . fta,v3' tit. I, -
20` 6 ft. ' IL
NC Well Contractor Certification Number a 15.OUTER CASING(for multi-cased wens)OR LINER(flap licable) -
FROM' Vvk ' TO, - DIA THICKNESS M RIAL
l ft LiS ft. s1
Company Name 16.INNER CASING ORTUBIIN (geothermal closed-loop) ' - -•
1 .� ��� FROM TO DIAMETER THICKNESS MATERIAL
2,Well Construction Permit#: t ft. ft. I in.
List all applicable well construction permits(Le.County,.State.Variance,etc.) in.
3.Well Use(check well use): "17.SCREEN . - .
Water Supply Well: FROM TO DIAMETER SLOT SIZE-' THICKNESS MATERIAL
ft ft. in.
❑Agricultural °Municipal/Public
❑Geothermal(Heating/Cooling Supply) I/Residential Water Supply(single) ft ft. in.
18.GROUT -
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL as EMPLACEMENT DIET OD&AMOUNT
Za
❑Irrigation 0 0 IL N A-,
Non-Water Supply Well: `
ft. ft.
❑Monitoring r ❑Recovery
Injection Well: it ft. ,
❑Aquifer Recharge . ❑Groundwater Remediation 19:SAND/GRAVEL.PACK(if applicable)--- -. . ' - -
FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Storage and Recovery ❑Salinity Barrier . ft rt. -
°AquiferTest °StormwaterDrainage ft ft
❑Experimental Technology ❑Subsidence Control
/ i 20.DRILLING LOG(attach additional sheets if necessary) ' .
❑Geothermal(Closed Loop) °Tracer FROM TO DESCRIPTION(color,hardness,soirroektype,Frain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) t) ft I b ft re_A c,�_ ` ,
4.Date Well(s)Completed: 9 -c3 °'Z'3 �T t.-
I® ft 2a n 7 n
Well Location: �/ ft V5 D ft 5c vel<s NCg j
5. � � `b c.k( clrh' `'3D ft. "� ft �� 5kQ1• J"
ft. ft. r
If._.: "-1--•. r-„-.r-- t
Facility/Owner Name • Facility ID#(if applicable) s n.,,..,. rliz,g )
i 6"t t D c)<a..nCres4 ft. ft. 0 C T 0 9 ��123
Physical Address,City,and Zip • 21.REMARKS .. . -
Meek- en Vc•g i3G- ri i -OS' ... • G; ... `.'a� rp
County Parcel Identification No.(PIN) I u `Lx:,`j4'
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: 1
(if well field,one lat/long is sufficient) r
25 .221520 N �© ‘5'1qb{� W /4 '� - e_ "�3
Signature of Certified Well Contractor Date ,
6.Is(are)the well(s): $lPermanent or °Temporary ,, By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
- with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or iiiNo 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#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back this page to provide additional well site details or well
8.Number of wells constructed: ' I 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:
1
9.Total well depth below land surface: "3 0 C> (fe.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if,different(example-3ta©200'and 2®100') construction to the following: I
10.Static water level below top of casing: 3 C ' (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: 0 (in.) 24b.For Iniection Wells: In addition,to sending the form to the address in 24a
12.Well construction method: V--aabove, also submit a copy of this form within 30 days of completion of well
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) Z Method of test: fic`t-'. 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
4 k the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: N % Amount: 1 r < \ 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 Ian 2013