GW1--06616_Well Construction - GW1_20231017

WELL COP1STRU+ ON RECORD i
Par Internal UseONLY:
This form can be used for single or multiple wells •
1.Well ContFuctor Information:
e •
awl \� 14.WATER ZONES. . 1. - .
,EN �`+ �'C,'J ir'� "re,(;, Oir FROM TO DESCRIPTION '
Well CantractorName a 001
ft.
2.0) C • HD rt. ft. 1 .
' NC Well Contractor Certification Number A • IS.OUTER CASING(for multi-cased;wells)ORL1NER(if up lteabie) '
FROM` ft. i t..� it. utAr I kin. , ?
D Mv1Vr s ip�1! r-e\1% `�
CompagyNome 16.INNER CASING OILT(IBI@IG(acotherinn)closed-loop) '
` FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: • 24.----00 ft. ft. 1 in.
List all applicable well•constpcdonpenults 6e.Countj.State Va,rance.ale.)
It Ih 1 itt.
3.Well Use(checkwell use): 17.SCREEN
a Water Supply Well: FROM TO DIAMETER 1 SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public it ft. in.
❑Geothermal(Heating/Cooling Supply) .Residential Water Supply(single) it. in.
•
['Industrial/Commercial ❑Residential Water Su• pply(shared) 18.GROUT
❑lll(QatiOII FROM TO MATERIAL a EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: f` 2�' ft- CPt1'T@ f'st-6 •
❑Monitoring t7R
ry
ecove ft' ft
Injection Well: ft. ft. i
CiAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if nppllcableZ-
ClAquifer Storage and Recovery ❑Salinity Barrier O TO MATERIAL riMMrr.ACEao�rrMETnoD
ra it: t
❑Aquifer Test ClStormwaterDruinage
R. It:
❑Experimental Technology ❑Subsidence Control
• 20.DRILLING LOG(attach additional sheets tfaecessary)
❑Geothermal(Closed Loop) ❑Tracer FROM ''TO DESCRIPTION(color.hardness,sa Wmetc typo,ncatn sirs,tin)
❑Geothermal(Heating/Cooling Return)et/ur� ❑Oth (explain under#21 Remarks) ® ft' 2 0 ft C.V��'
4.Date Well(s)Completed: "t � ' T�2 3 "2'0 ir. fib <t• a�L�.r, c e
11
S.Well Location: 80 ' ii0 it. Stvi,444` s� o
DCR,n.e� P O- ,'eca Leer 12e� ,t blue .si 7-'-''i %IL,t
Facility/Owner Nome FaciliryIDfl(ifapplieabie) ft
6 e S y s 1c.. Cadoer 12-� ft. ,t. 0 C T 1 7 2023
Physical Address,City,and Zip Z1.REMARKS t r,
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
Orwell field,one letllong is sufficient)
.G i LliCifi64 N cSoM71460 W R 9 11.023
Signature of Certified Well Con etor i Dare
6.Is(are)the well(s): OPertnanent or OTemporary By signing this ibrm,I hereby ce rf that the well(s)was(were)constructed in accordance
with 1511 NC,C 02C.0100 or 154 NCIIC 02C.02OP Wall Construction Standards and that a
7.is this a repair to an existing well: °Yes or No copy of dris record has beenprovided to the well owner.
If Ibis is a repair,fill out/mown well construction it formation and explain the nature of the
repair under#21 remarks section or on Use back of this form. 23.Site diagram or additional well:details:
p You may use:the back of this page to provide additional well site details or well
9
• 8.Number of wells constructed: construction details. You may also attach additional pages if necessary,
Far multiple Infection or non-water supply wells ONLY witli the same construction,you can
submit onefarm. S 24.Submittal Instructions:
9.Total well depth below land surface: Z.0 0 (f) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths lfdl',�erent(example.3Q200'and 2Q100) construction to the following,
10.Static water level below top of casing: 1® f ({L) Division of Water Quality,Information Processing Unit,
' If newt level is above casing,use••+•• 1617 Mail Service Center,Raleigh,NC 27699-I617 •
11.Borehole diameter: f 1li3 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
�.+ above,also submit a copy of this farm within 30 days of completion of well
12.Well construction method: �®r r+bir*9 construction to the following:
(I.e.auger,rotary,cable,direct push,etc.) 1
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: AA , 1636 Mail Service Center,Raleigh,NC 27699-1636
13w Yield(gpm) Method of tes& d'r\ 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
i the addresses) above, also submit;one copy of this lean within 30 days of
13b.Disinfection type: �T \S Amount: k C)f t ` . completion of well construction to the county health department of the county
where constructed.
Fenn GW-1 North Carolina Depattmentoflinvironnlent and Natural Resources-Division of Water Quality Revised Ian.2013