GW1--06646_Well Construction - GW1_20231017

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WELL CONSTRUCTION RECORD For Internal 1.15c ONLY:
This form can be used for single or multiple wells
1.WellaContra torInformation• c
1�e1v i 1� 14.WATER ZONES. I -
AIL C' 0,J iln 0 Cn Co IDS 6/1 FROM TO DESCRIPTION •
Well Contractor Name 1!_0 f£ ft.6S6 ., t© � ft.
NC Well Contractor CenifcatiokNuntber 15.OUTER CASING(for mulls-cased wells)OR LINER(if applicable) . .
c FROM TO D TER TIUCICNESS MATERiAT.
b� \K \\t% \e11 '�r t`tr .-r ft WI It: tot IS m. !Z 5 PVC.
Company Name 16.1NNER CASING OR•TUBIltl (Reothermalcjosedaoop) ' • •
` '�°� FROM TO DIAMETER TRIMNESS MATERIAL
2.Well Construction Permit it: a e • ft. ft in.
List all applicable well construction penults(i.e.County.State Variance.etc)
f£ ft • in.
3.Well Use(checltwell use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural [Municipal/Publicft.
ft. In.
❑Geothermal(Heating/Cooling Supply) RDResidential Water Supply(single) ft. in.
❑lndustrial/Commercial (]Residential Water Supply(shared) 18.GROUT
❑Irrigation FROM TO MATERTAL `°� Ey1PLACEMENTM TROD&AMOUNT
Non-Water Supply Well: R' n' Berl art 1" ' ��j0
OMonitoring ❑Recove R' ft.
ry
Injection Well: ft. ft.
❑AquiferRecharge ❑GroundwaterRemediation 19:SAND/GRAVEL PACRjtfapplicablo) •
❑Aquifer Storage and ltecovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
n ft
❑Aquifer Test ❑StormwaterDrainage
❑ erimental Technologyft.
>� ❑Subsidence Control
❑Geofttetmal(Closed Loop) ❑Tracer 20.DRiLLINGLOG(attaclradditionat sheets ifnecessary)
FROM TO DESCRIPrTION(color.hnrttoess,soWrocktypa Frain size,en.)
['Geothermal(Heating/Cooling Return ❑Other(explain under#21 Remarks) ^>>�f'' 35' � P.eµJ ` 10,LL- / 1
4.Date Well(s)Completed: �" 11-3 ✓ / f O ft re[i-�/ e t'►�� C t ytG-
5. ell Location: /lO ft. 15 y7 it'7`' V lrtA tJ e(
1t ,#`-,. rt. gi2a �G ��-cl t1 ��
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
Soo i-letvair�er Lf, ft. p -
Physical Address,City,end Zip 21.REMARI(S •may ` y e {`�Y 'T:
OCT 1 7 2023�
County PatcetldentifhcationNo.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: i nr±*'TM",. W' ;'. ..:.=.,:;
(if well field,one let/long is sufficient) 22.Certification: Ct.�:+,•+., _3 I if
. 6 Q 24 N f3 C, S'I G.00 w f ,a e) t-z 7t-z3
Signature o C rtified Well Contractor i Date
6.Is(are)the well(s): *Permanent or ❑Temporary
By signing this form,I hereby certify that the wells)was(were)constructed In accordance
with ISA 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 iiilNo copy aphis record has been provided to the well owner.
Olds is a repair.Jill out known well construction h formation and explain the nature of the
repair under#21 remade section or on the back of 1h1 form. 23.Site diagram or additional well details:
`( 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 constiuctlo,,you can
submitonefarm. 24.Submittal Instructions:
//�� /
9.Total well depth below land surface: 7 (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@200'and 2@700) construction to the following
10.Static water level below top of casing: .; (ft) Division of Water Quality,Information Processing Unit,
limiter level is above casing.use.+" if 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole dlnmeter:
(in.) 24b.For Injection Wells: To addition to sending the form to the address in 14a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: k%Ir J^1 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: k 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 Method of test: l f 24c.For Water Supply&[Geothermal Wells: In addition to sending the form to
the address(es) above,• also submit tone copy of this form within 30 days of
IA
13b.Disinfection type: Pr i Amount: `�A completion of well construction to die county health department of the county
where constructed.
Fort GW.1 North Carolina Departrnent of Environment and Natural Resources-Division of Water Q I lity Revised Jan.2013