GW1--06490_Well Construction - GW1_20231013

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:\ % L
Ke 1 n r k1 e\\�.• 1 G Gl\i t e> lj�C. T�:S OrN 14.WATER ZONES. P
FROM TO DESCRIPTION
Well Contractor Name ft. 130 ft.
2 0 eI 6 •r \bb s. xio ft 1 1
NCCWell Contractornt' Certification Number,' ` ` IS.OUTER CASING(for multi-eased wells)OR LINER(if applicable) •.. .
Y` v..3\\ i'ER THICKNESS MATERIAL
r WeA\ 4r‘,\1 1 '.� I ft. `log;ft &'I5 m' ]2S PVC.
Company Name 16.INNER CASINCG3OR-TUBING(geothermal closed400p) . -
�^�d FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 2- C\— 6 . ft ft in.
List all applicable well construction permits(i.e.Counga State,Variance,etc.) in.
3.Well Use(check well use): 17.SCREEN - i.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft ft. i in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT... -
FROM TO MATERIAL '- EMPLACEMENT METHOD&AMOUNT
❑Irrigation O ft- ` -0 ft. (3aateC4**\ tout-�4
Non-Water Supply Well: ft. ft
❑Monitoring ❑Recovery '
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
ft ft.
[Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control \ '
20.DRILLING LOG(attach additional sheets if necessary) . - ' -
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soWrocktype.grain size,etc.)
❑Geothermmal(Heating/Cooling Return) then(explain under#21 Remarks) 0 rt. ft rid CACa.�/
4.Date Well(s)Completed: t I 1 ��2 3 'Z6 ft' oft } ittc
`) ' f7D ft
5.Well Locution: b f v �1 ge^C.v�
00 ft 115 ft . -u1.14-e
IWA-kirlr,V... Ti 5o In 1` S ft 2x, ft S. ive 51_aA•c
F
raccility/Owner Name C Facility ID#(if applicable)
ft. ft. I' 9-._.i' E g_
Physical Address;City,and Zip 21.REMARKS 0 C I 1 ,' ZQL J
fir..O� 014—306-� %
County Parcel Identification No.(PIN) i• °m...i r -"1 i'r
nt.c: `3 1i r,,'
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: t'
(if well field,one lat/long is sufficient) 22.CQZ tiilCatiOn: ( r
Sul. 6Qget N (6DI� ,Jc.4a3Z W ' .�1 g 11 £32e
Signature of Certified Well Contractor Date
6.Is(are)the well(s):JDPermanent or OTemporary 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: ❑Yes or 8No copy of this record has been provided to the well owner.
!f 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 of this pageto 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:
9.Total well depth below land surface: 200 (ft.) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths ft-different(example-3©200'and 2(0100') construction to the following: i
10.Static water level below top of casing: '1(a 0 / (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: 6 'IR (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
12.Well construction method: c1/4,-•-../ • 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) 20 Method of test: A% q 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
13b.Disinfection type: 1� Amount: p',h 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 Jan.2013
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