GW1--06769_Well Construction - GW1_20231023

WELL CONSTRUCTION RECORD
This farm can be uscd for single or multiple wells For Internal Usc ONLY:
1.Well Contractor Information:
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FROM TO DESCRIPTION
Well` Contractor�� B (Nome / ) I 0 A Y //e; ft.
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NC Well Contractor Certification Number
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��ff ,�y �t ;:15f:0UmeltEASING'(forurfiltJ=case8walla).ORT�INER:(ifop-Berlin:' •'>,rt':;•;;:;:,.,:
0� �u — " FROM it. r TO ft. I DIAMETER in. I THICKNESS 11fATERIAL
Company Name �J '1 !.16:1NNER ICASING':OIV'TOBING:(geotlidarial:dnscd-loo'
2.Well Construction Permit Il:D'C I��(1 FROM -TO�/ DIAMETER • . THICKNESS MATERIAL '
List all applicable well construction permits(i.e.Cornry,State,Variance,etc.) / ff. Y ft. //� II'.
�V p �,I�7
ft. ft. I• in, V1` V V
3.Well Use(check well use):
'37.SCREEN . :,:. , •i,L !:•: • -
Water Supply\Vell: FROM TO DIAMETER SLOT SI THICKNESS MATERIAL '
❑Agricultural ❑tvtun' ipal/Public ft. ft. in '
❑Geothermal(Heating/Cooling Supply) t8i esidential Water Supply(single) ft. ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) P•is,:GROUT+.:=' ,:!
❑Irrigation FROM TO 6 ft. ATERIAL � A i IaCEAfENT METiIOn&�AMOUA-(/NT
Nou-Water Supply Well: s r
t" rt. °'.1� U
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❑Ivionitoring ❑Recovery ft ft. z�1ai41; C. 1 fi ` .-©�
Injection Well: ft. ft. C11
❑Aquifer Recharge ❑Groundwater Remediation 19i'SAND/GRAVEIPPACIi(if:ariplienble) -,':-..":1;:_;.••.;4:.',•;:;'.';: •;;,:.;. ;
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
'
-
❑Aquifer Test f. rt.
❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothennal(ClosedLaop) OTracer '•20:DRILLING:LOG•(uttndindditionalsbacls'ifn'eecisnry' "::'„";::.:.c.;•::_ ..c;
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DEs��.``�``PTION(coler,hardness,WI/rack type,grain size.etc.)
4.Date Well(s)Completed: 4L CAS' ft. ' / ir. t ./%� /4e�d coy L5/4
5.Well Location: ft. ,r/T? ft, the*da I //..4+
vbc��A . 'psi,e� 47 rt. ZD6 ft. data.. ��x-t�
Facility/Owner Name ft. ft. Fi -_ „...
1��� l Facility IDN(if applicable) ft. t. p'4,W y
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Rec�t'� 0 (�� �� a �.�...
Physical Address,City,and ft ft. U�.. I .J �l'23
V7cJ41 C0 /cJ fJ (1 / fp :`Z1:ItEh4ARK$t i rifor, : l''
County Parcel Identification No.(PIN)
1
5b,Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one JatAong is suiLcientp 22.Certification:
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N eb 1 6 yin
t&I�mture ofCertifed well Contractor -
6.Is(are)the well(s): I 'Pernf IIanent or ❑Temporary Date
By signing this fora,I hereby cerl that the well(s)was(were)constructed in accordance
•
7.Is this a repair to an existing well: Oyes or PNa with ISA NCAC 02C.0100 or!SA NCAC 02C CO200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided lo the i'veU owner.
repair under ii21 remarks section or on the back of thisfora. 23.Site diagram or additional well details:
8.'Numbet of wells constructed: a1�C •
You may use the back of this page to provide additional well site details or well
For nurltlple injectionor non-water supply veils ONLY with the same construction,you can construction details. You may also attach additional pages if necessary,
snbmu one joint. 1 24.Submittal Instructions: ,
9.Total well depth below hind surface: cA 06 '
For multiple irerls list oil depthslfdderen!(example-3Q200'and 2 r 100 (fr,) 24a. For All Wells: Submit this form'Within 30 days of completion of well
4 construction to the following:
1.
10.Static water level below top of casing: 0 (ft.) Division of Water Quality,iInformation Processing Unit,
•
!Prater level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617 .
11.Borehole diameter: (o (in.) 24b.For Inicetinn Wells: In additii4 to,sending the form to the address in 24a
12.Well construction method: r $j"y above, also submit a copy of this form Within 30 days of completion of well
(i.e.auger, construction to the following: I
grotary,cable,direct push,etc.) h
Division of•Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I3a.Yield(gpm) /6 Method of test: Ikk r 24c.For Water Supply&Geothermal Wells: In addition to sending the form to�ryry the address(es) above, also submit one copyof this form within 30 days of
13b,Disinfection type. I Q-O II Amountf1'e.Lll 7a ® completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality
Revised Ian.2013