GW1--06617_Well Construction - GW1_20231017

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
1.Well Contractor Information:r '�
CA lI (n s�L l .14;.WATER:ZONE
FROM TO DESCRIPTION
Well Contractor Name I LID rt. 16 0 ft C-
CAb 39 P. A
•
ft. ft.
N'Well
lCContractor Certiti Number t ::15itOUTER•CAS!NG:(for'n,oltl.cashdwcls)'ORLINER(ifdp'Ifnt6lc)':'
�s+ � `^' \✓g 1 l,o f M R.
I TL ft I t s R IR THICKNESS MATERIAL
CompanyNamc YYY v 1�; I���oa_lp) PVC
'16i?INNER''CASING'OR TURING.(geothiernarelbied-loop)
v1.71�. �� FROM TO DIAMETER- THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. ,n
List all applicable well construction permits(i.e.County,State,Variance,etc.)
f. ft. ,in:
3.Well Use(check well use):
17.SCREEN •I • . t:I
Water Supply Well; FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL `'
❑Agricultural ❑Mun ipal/Public ft ft ti •
❑Geothermal(Heating/Cooling Supply) E36sidential Water Supply(single) ft. ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18•GROUT
❑Irrigation FROM11 TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: u ft, i l 0 ft. lit toe h I tC,
Pa.)red (�,
OMonitoring ❑Recovery ft ft Gh
Injection Well: ft. ft. t S
❑Aquifer Recharge ❑GroundwaterRemediation ;19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stommater Drainage
ft, ft. /
//
❑Experimental Technology OSubsidence Control tr. ft.
• ❑Geothermal(Closed Loop) OTracer ^10.`DRILLING'LOG'(attachadditional sheets'ifn'ecessarv) • .
FROM TO - DESCRIPTION color.hardness,sail/rack type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) .❑Other(explain under#21 Remarks) CI ft• 1 D ft.
So► �
4.Date Well(s)Completed: 0 1 — a 0 3 y(� ft tt ��'Q,L
5.Well Location: ft bn fr. S Abn fr• 2,60ft Q..
Chr;S ft. ft.4o9h49,1 Je,-,K;n5 s�a�
Facility/Owner Name Facility ID#(if applicable) �,,.} `r.��F ,.g-
ft, ft r' �_„it� .ny
4ga°l sloe.. 1 ,06+ Ind , ft. ft. 1 ULI 1 , ZL�23
n
Physical Address,City,and Zip
C� 21:'1tEMAitI{S 4
C.Gbarrv_ cl rig ,,rt&31:F5f
County Parcel Identification No.(PIN) DL',...Z`3
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(Wore(field,one lall tlong is sufficient) 22, a ti cation:
•
36-D a3 N 3 0° as '39 w /-1,41
�� � igna of Certified We!Coals-actor Date
6.Is(are)the well(s): (1114r ranent or ❑Temporary
By sigi ing this form,I hereby certify that the'wcll(s)was(were)constructed in accordance
with 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or o
If this Is a repair,fill out known well construction information and explain the manure of the Copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
GYou may use the back of this page to provide additional well site details or well
n
8.Number of wells constructed: construction details. You may also attach'additional pages if necessary.
For multiple hfection or non-water supply wells ONLY with the same construction,you can
submit oneform. 24.Submittal Instructions:
9.Total well depth below land surface: act 0 i (fL) 24a. For All Wells: Submit this form:within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2©100) construction to the following:
i
10.Static water level below top of casing: �0 • (ft.) Division of Water Quality,In
u formation Processing Unit,
If water level is above casing.use•'+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
bIt
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition tol 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: l2.0 4-aril. construction to the following:
(Le.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
i\ /•
I
13a.Yield(gpm) Method of test: ){h tf 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: )C.� 1) _!t$ Amount: oC(`t)y r�a,41.. completion of well construction to the county health department of the county
Iwhere constructed.
Form OW-i North Carolina Department of Env ronment and Natural Resources—Division of Water Quality tY Revised Jan.2013
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