GW1--06765_Well Construction - GW1_20231023

WELL CONSTRUCTION RECORD For Internal Use ONLY: .
This form can be used for single or multiple wells
1.Well Contractor Informatio
dN� till:VATERi2ONE9•t,.i .:(h: ..: ,1• :. ,A't.....`
� v-Y �f e ��� FROM TO DESCRIPTION
Well Contractor Name e2 co ft. J©ofr. I? OA�s3S
cAcg3© - A ,66D ft ft: 6d 16 Al/D,rs
NC Well Contractor Certi tionN her ,15a0UTEICCASING.`(for:multi•ease3:wells)'OR`I�INER:(ifap lieulile)':::�: '+::'z �-
/ _� I. � FROM TO DIAMETER THICKNESS MATERIAL(�
1��JC Ll Si '`�mt E 1�1Ffl fir;��;Ali I ft j ft. t//�,, 'n.tlok z/ T (1C
Company Name �J .16.INNERCASING':OD TUBING:(geotiieitnnl:dasedloep) . -'_ , r;!
FROM TO DIAMETER THICKNESS s MATERIAL
2.Well Construction Permit#I: S 73�tA4 ft. ft. in.
List all applicable iyell constrtrctlon permits(i.e.County,State,Variance,etc.) ft ft in,
3.Weil Use(check well use):
'..T11.7.,SCREENr:i-.it.li.Wff. -7,/.., .c...;; : 'g ',_•s,r" ;,.+:..r .-+..':;'.: ._..... _
Water Supply Well: FROM TO DIAMETE SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft.
❑Geothermal(Heating/Cooling Supply) IIRIM1dential Water Supply(single) • ft ft' iu.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18?'GROUT ' :1 f- r=.:: :.... ...::t,
FROM TO fATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigationft. ft. '� ,,
Non-Water Supply Well: 16 7y�
ft. ft.
❑Monitoring _ . . ❑Recovery .
Injection Well: ft. ft.
OAquifer Recharge ❑GroundwaterRetnediation 19'SAND/GRAVItL'PACK(ifappifcable(h ,n: -%.:
❑Aquifer Storage and Recovery • ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft. '
❑Experimental Technology OSubsidence Control
20 DRILLING.L'OG"(at'taeli"additional'shcrrta if•iiecessani) : -..
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION color.hardness,saWrock type.grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under 1121 Remarks) d it a it. gar!4.Date Well(s)Corn leted: �0 'c0oZ0 OS ft3T fr." et t�dL
p Is- ft 69 ft. , /ere z
5.Well Location:_s 1? •
/� ft. 6, ft '
A t s.fl i e fin?I f ly ft. ft. 1
Facility/Owner Name Facility 1Db(if applicable)
�i4 a N C. �O1 I4 W tiakLQRO tk1)ft. ft. I 1.1 2,:: 2023
Physical Address,City,and Zip 21.urMAi (S t 7 ;_
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:(if well field,one let/long is sufficient).
•
.31° .N p4° W I /O4err?O sqrA
Signature of Certified Well Contractor i Date
6.Is(are)the well(s): errnanent or ❑Temporary By signing this form,I hereby certi that the well(s)was(here)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 IVell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or o copy of this record has been provided to th/well owner.
If this is a repair,Jill out known well construction information and explain the nature of the
repair under 021 remarks section or on the back of this farm. 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: d NICr 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. /� 24.Submittal Instructions: ' '
�•9.Total well depth below land surface: etO t (ft.) 24a. For Alt Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdderent(example-3 r©200'and 2Q100) construction to the following:
LI_At
10.Static water level below top of casing: TV (ft.) Division of Water Quality,Information Processing Unit, •
If water level is above rasing;use"+" _ 1617 Mail Service Center,Raleigh,NC 27699.71617 .
f
11.Borehole diameter: `� (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
‘—�•[�C) t G above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: l\ construction to the following:
(i.e.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
l 13a.Yield(gpm) I Method of test: �l &r 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: I NIA t 6 Amount: completion
of well construction to the county health department of the county
e where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013