GW1--06767_Well Construction - GW1_20231023

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WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY: I
1.Well Contractor Information: 1
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"1a.Wi1TER'ZONESrr; .,;.?`.E,r;•';:'.p..{n .,:...,-,..,..
FROM TO DESCRIPTION
Well Contractor Name p , �9$ft. Sep'''.
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La •s 1 is ► i je// `7 KM i I1 A� WLJ (.3t N�Q
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NC Well Contractor Certification Nu bar Y v
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1 Contractor 'PROM ER:CASING'(for'inulii•caseBaElls)`OR7;INER(ifOil-1;nbTERIA :'•;,,.;:;'' .
`P��[`V.C{/ ., FROM I.T0� � A� R ii in. �TIIhIC[QWFSS h7A(T�El7/ALe
ry
Company Name ��� 'SO::INNER CASINGIOR+TUHiNG:(ficetilei nal'eliudd-loo) �•- .•'.. .
- FROM - ,TO DIAMETEI THICKNESSMATERIAL. .
2.Well Construction Permit#: •,.5 LLL��� ! fr. ft. in.
List all applicable well construction permits(i.e.County,State,Variance,etc.)
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3.Well Use(check well use): tr. fr. in
'41:SCREEN:I-• .i.:.i,:;.,:,!:.. :....i:r'::;::?'i': :¢ ..::5 l:i::.i•:'r'-:•:"_'.i. ':;:.'•'.;.•:
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL 1
❑Agricultural ❑Mu al/Public ft. ft. m
nich
❑Geothermal(Heating/Cooling Supply) id Supply Water Su I ft. ft. to —
g ;
❑Industriol/Commercial ❑Residential Water Supply(shared) `''18dGROUTn ('
❑hrigatinn FROM TO M1IATERIAL' LACEMENThIETHOD&AMOUNT
Nou-WaterSupplytiVcll: D ft A '11 ,Jet SO—G
❑Monitoring ❑Recovery ft. ft. LI i l � / /LtC . eCi��
Injection Well: ft. ft. /UfT/ t-
❑Aquifer Recharge ❑Groundwater Remediation .19:SAND/GRAVEL'RACKW.i(iptieable) -?=zS,..i: s;r.'•;,::•' :.•;:,••.... ,,
FROM TO
❑Aquifer Storage and Recovery MATERIAL• EMPLACEMENT
ry' ❑Salinity Barrier
ft. ft❑Aquifer Test tormwater Drainage .
❑S
❑Experimental Technology ❑Subsidence Control ft' ft. I
OGeothermal(Closed Loop) ❑Tracer ',M DRILLING;LOG(attrach nilditioaal•alicots if necessery)+ ::.),c_,:,:;z•:; ;•::.::r;:
FROM TO - DESCRIPTION(color,hardness,salUredce. '❑Geothermal(Heating/Cooling Return) ❑Other(explain under 1121 Remarks) ® tyre.grain size,era)
7 ft. ao tit. �o�,L
4.Date Well(s)Completed: it 1 't C oZ� to Co ft• ,(4' fr. C5O��l_/ el
Toell Lo tion: � i� -it L�•s Lse _
I.lp; fl Sidi ie 41 ft. 6o ft: c='0%d Ace_
v Facicility/OwnerName FacilityIDM ifa ft. ft. ; ,_
I. (JI�9 Mail (( applicable)
( `'s>, .. 1"ti�.
Mw ! /J� v+ A L.a ft. ft. r ��:. .m r: +4s 5 . d
Plrysiea!Address,City,and Zip �� ft. ft rt
;f2iAiRMA1tKS 0( T ? 2Q23
County If'a ...kr!^l P. ?.Y , S`1 (
Parcel Identification No.(PIN)
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5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field onelnt/long is sufficient)' 22.Certification:
t&Iallure of Certified L2E!!' 6 6.Is(are)the well(,): eGihl7 rntanent or ❑Temporary j Date
Itai� By signing this form,I hereby certify thati`the well(,)was(were)constructed in accordance
7.Is this a repair to an existing well: qy� er o with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 IVeil Construction Standards and that a
!phis is a repair,fill out known well construction it formation and explain the',attire 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:
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&Number of wells constructed: You may use the back of this page to provide additional well site details or well
For nudttple infection or non-waiH'supply wells ONLY with the sante construction,you coo construction details. You may also attach additional pages if necessary.
submit one,form,
s 24.Submittal Instructions:
9.Total well depth below Ignd surface: ,W f
For multiple wells list all depths jdijjerent(example-3Q200'and 2 100 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
Q construction to the following: 1
10.Static water level below top of casing: 4'01 (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,sae"+'• 1617 Mail Service Center,Raleigh,NC 27699-1617 .
11.)3orehole diameter: (in,) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: ' 5-(-.6_ above, also submit a copy of this fiirrn within 30 days of completion of well
(i,e,auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY:
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) IA Method of test: k,r 24e.For Water Supply&Geothermal Wells: In addition to sending the form to
6 the addresses) above, also submit one'copy of this form within 30 days of
13b.Disinfection type: IA k{ Amount C74 tip Completion of well construction to the county health department of the county
where constructed.
Foim GW-I North Carolina De I
partment of Environment and Natural Resources—Division of Water Quality
Revised Jan.2013