GW1--06494_Well Construction - GW1_20231013

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells •
1.Well/A/Contooractor Infornation: -
cid. r u I l// i �) 14.WATERZONES . - fI -/4L V FROM TO DESCRIPTION
Well Contractor Name
70 ' f. li
203'3 .r. / oft ft.
15.OUTER CASING(for multi-cased wells)OR LINER(if ap Reabie) '
NC Well Contractor Celification Num/berms /1 ///l FROM TO DIAMETER THICKNESS MA
IAL
!� / 1 a/l,5 L'e,Il l[/✓�llm -I-1 ft" I 63 ft 16 7Di in. I . /ZJ Al• 6i
16.INNER CASING ORTUBING(geothermal closed-loop) •.-. • - -
Company Name FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: Z 3 - S ft.
R I, in.
List all applicable well construction permits(Le.CounO:State.Variance.etc.) ft ft. in.
3.Well Use(check well use): 17.FROM REEL�O DIAMETER SLOT SIZE THICKNESS MATERIAL
Water Supply Well: ft. ft. !in.
[Agricultural ❑Municipal/Public in:
ft ft
['Geothermal(Heating/Cooling Supply) AItesidential Water Supply(single) 18 GROUT
❑lndustriai/Commercial ['Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT M OD&AMOUNT
❑Irrigation 0 " ft iJ�ntro lest)
Non-Water Supply Well: ft. ft.
[Monitoring [Recovery ft ft.
Injection Well:
[Aquifer Recharge ❑Groundwater Remediation 19;SAND/GRAVEL PACK(if applicable)-- - ���c. I,METHOD
FROM TO MATERIAL
['Aquifer Storage and Recovery ['Salinity Barrier ft. ft
[Aquifer Test ❑Stormwater Drainage ft. it.
❑Experimental Technology ['Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary) -
❑Geothermal(Closed Loop) ['Tracer FROM TO A DESCRIPTION(color,hardness,soltirocktype,grain size,etc.)
OGeothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) 0 ft 3b ft 4,„,,
4.Date Well(s)Completed: -� 1 3 © ft ft* s��clay?/�
5.Well Location: • ft ft.
' // / a- rr�, ter✓ Q [-` cw.
a.'F�ta.P��Q. V-� Tw.✓ —14�Vs^I ��-- 1 i � It �-�;!-.:,�;"� - .5 f,,.�
Facility/Owner Name
Facility ft ID#(if applicable) ft: ': r * h ;_,..
��}}(
I t11.
3 '1� t0�t� Le. I JI ---a It. ftt. ?n23
Physical Address,City,and Zip o "Pie ✓f. C. Z '//c7 21.REMARKS I� :a„„..,...„ 0602-410VD� � : • ,^.:t
z rn i1r5z �•� Y�
County
Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: /// rr11 �f
(iF wall fi ,ono Inc 4 sufficient) 'C ( (L I ( 3
�. -R c 1 2-
� OO H 3� N W iCont_actor Date a
�� Signature of Certified Well Contractor
6.Is(are)the well(s): 13Permanent or ❑Temporary By signing this form.I hereby certify,that the well(s)was(were)constructed in accordance
with ISA 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 1iiIVo
copy of this record has been provided to the well owner.
If this is a repair,fill out blown well construction it formation and explain the nature of the 23.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
S.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. �
9.Total well depth below land surface: ( J' (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following.
For multiple wells list all depths ifdifferent(example-3(}00'and 2Q100�
Z0 (�) Division of Water Quality,Information Processing Unit,
I fw Static water level below top of casing: 1617 Mail Service Center,Raleigh,NC 27699-1617
If hater level is above casing.use % I
/o (in. 24b.For Injection Wells: In addition to sending the form to the address in 24a
li.Borehole diameter: O above, also submit a copy of thi s'form within 30 days of completion of well
/�j a/� •
construction to the following:
12.Well construction method: f//✓
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-I636
13.FOR WATER SUPPLY WELLS ONLY:
-� (, r, 24c.For Water Supply&Geothermal al Wells: In addition to sending the form to
13a.Yield(gpm) Z-� Method of test: I ► the address(es) above, also subs lit one copy of this form within 30 days of
(J\.....
completion of well construction to the county health department of the county
13b.Disinfection type: Amount: where constructed.
IS Revised Jan.201
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality