GW1--06492_Well Construction - GW1_20231013

WELL CONSTRUCTION RECORD For Internal Use ONLY: •
This form can be used for single or multiple wells
1.Well Contractor Information: t I
1 l\ ��- ' P
)�rV r LJ�1�� ��J V J c a►'� FROM
ZONES .TO DESCRIPTION .
Well Contractor Name ft ft L
2 6el.E, ft. ft. 1 1
NC Well Contractorw Certification Num`b�er1 [ s FROM T 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licabtlee))'-- .. •
b .. 1`I\J\ ems WQ\\ \)r' \% rN .. - 1 ft- TO
6 1 m. ir`C2.S �KNESS MATERIAL
Company Name 16.INNER CASING OR TUBING(geothermaldosed-loop) - ' .
c FROM TO DIAMETER THICKNESS MATERIAL
2,Well Construction Permit#: 23 '- J ft. ft. , in.
List all applicable well construction pennits(i.e.County.State.Variance,etc.) •1ft. in.
3.Well Use(checkwell use): 17.SCREEN -- -- - - • . .
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft.
❑Agricultural ❑Municipal/Public ft. in.
OGeothermal(Heating/Cooling Supply) klResidential Water Supply(single) ft: it in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT :. - - • -
FROM TO MATERIAL \ EMPLACEMENT MET OD&AMOUNT
❑Irrigation 0 ft �0 ft %tdll�i OVC'
Non-Water Supply Well:
❑Monitoring ❑Recovery it ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19;SAND/GRAVEL PACK(if applicable)------. - : -. .. '- -
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 1 ft. it 1
❑Aquifer Test ❑Stormwater Drainage •
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach hdditioatd sheets if necessary) .
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soillrocktype,grain size,etc)
OGeothermal(Heating/Cooling Return) 01
Other(explain under#21 Remarks) 0 ft /O ft t ai C,> � t
4.Date Well(s)Completed: )\1 23 ft' 9-0 �1 SO`\ 1 $4 S re
2.0
ft LID ft c l-,d\e, t to G F-.
5.Well Location: 4 O
ft 540 it blue 5,CA# , ),,,._
+-0,5 C7.--, i'1 ‘ ft. ft.
Facility/Owner Name FacilityID# a applicable)
tY (ifPP ) ft. ft. r „r. , ,
"3‘ ' G tS-.y2' &\r1 � ft ft. rT �...
2
Physical Address,`Eity,and Zip 21.REMARKS Q L -. .iQLo
'County Parcel Identification No.(PIN) i L°•"C ^ '�i7
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: •
22.Certification: I
(if well field,one lat/long is sufficient)
+�C Q,��+ /yam{ 1 A r� r Aitz±3
5• 15VJy N b. tt 0aq W
Si o - ed Well Contrac r Date
6.Is(are)the well(s): l'JPermanent or OTemporary By signing this form,i hereby cerlify that the well(s)was(were)constructed in accordance
with 15A 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 igNo copy of this record has been provided to the well owner.
If this is a repair,fill out'mown well construction information and explain the nature of the I.
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 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. u /� I 24.Submittal Instructions:
9.Total well depth below land surface: S 1 v (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 a@200'and r2@I00') construction to the following:
10.Static water level below top of casing: \.J (ft) .Division of Water Quality,Information Processing Unit,
If water level is above casing.use "1 i 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For infection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this forth within 30 days of completion of well
' 12.Well construction method: 19--CrIcA N-- construction to the following ,
(i.e.auger,rotary,cable,directpush,etc.)
Division of Water Quality,Underground Injection Control Program, ,'--,
13.FOR WATER SUPPLY WELLS ONLY: \ 1636 Mall Service Center;Raleigh,NC 27699-1636
13a.Yield(gpm) I 0 Method of test: \'c't 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit oriel copy of this form within 30 days 13b.Disinfection type: Amount: \ i of
- f� tt 1 completion of well construction to the county health department of the county
1 where constructed.
Form GW-1 • North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013