GW1--06799_Well Construction - GW1_20231023

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well.Contra torInformation:
\��1'r1 \\� 0.v\r� ®L,40 FROM WATER ZONES DESCRIPTION
Well Contractor Name/ ft. el s ft !
2a3 1, .s. ft. 1176 ft
NC Well Contractor Certification Number
` i a _ IS.OUTER CASING(for multi-cased wells)ORI,INER(Wap liable) . •
FROM TO ERIAL
t)`— I . `` t \a€ \ tor- \\\(Ns 41 it HS ft ��aR m• rstclavESss Ins?C'
Company Name 16.]NNER CASING OR-TUBING(geethertnalclosed-WO '
FROM TO DIAMETER TWWCIINESS MATERIAL
2.Well Construction Permit#: -3ci e 3R3 it: ft. ' in.
List all applicable well constructionpermits(i.e.Count):Stag Variance.etc.) —
3.Well Use(check well use): 17.SCREEN • ' •
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural 17Municipal/Public n IL
❑Geothermal(Heating/Cooling Supply) 41PResidential Water Supply(single) it In.
❑industrial/Commercial OResidential Water Supply(shared) •18.GROUT '
FROM TO MATERIAL ., EMPLACEMENT OD&AMOUNT
❑imination bo ft , ft
Non-Water Supply Well: Q2p0 Ya1�C ft.❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK(if applicable)- '
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOb
m ft. I
❑Aquifer Test ❑Stormwater Drainage it; ft.
❑Experimental Technology ❑Subsidence Control 1 •
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM ' TO DESCR�N(calor.hardness,solllrock type.grain she,etc.)
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under1121 Remarks) C) ft U)ft p C, c /1
4.Date Well(s)Completed: Ca"— i ,0 f t "�'`'' b�1�'�r S(ark
ft. ft.
5.Well Location: tt. R,
Facility/Owner Name Facility ID#(if applicable)
(U•T 9
-fib% •'Icc J _ ft. it. 2023
Physical Address,City,and Zip 21.REMARKS i n i c..g m_, .n :-',--_. --,I t,-v
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: '
Orwell field,one lat/loas is sufficient)
w • /L �5.Ick- L-r9a N (8at32‘1�zt • 52 131 123
� l-
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ligPermanent or ❑Temporary By signing this form,I hereby certify that the well(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 >d(No copy of this record has bean provided to the well owner.
phis is a repair,Jill out known well contraction I!formation and explain the nature of the
repair under#21 remarks sectIon or oh the back of thisfota,. 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: 1 construction details. You may also attach additional pages if necessary.
For multiple hifaction or non-water supply wells ONLYwitii the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: • &CEO 0 (it.) 24a.For All Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depths ifdlferent(example-3©200'and 2Q100' construction to the following: i
P Division of Water Quality, Processing
10.Static water Ievel below top of casing: `�0 (ft) Information Unit,
tinter level is above casing,use"" F r 1617 Mall Service C;nter,Raleigh,NC 27699-1617
11.Borehole diameter: I a (in.) Z4b.For Infection Wells: In addition to sending the form to the address in 24a
r°12.Well construction method: Po
/. above,also submit a copy of this iform within 30 days of completion of well
construction to the following: I
(i.e,auger,rotary,cable,direct push,etc.) I
Division Of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: ( t 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) Method of test: I` \ 24e.For Water Supply&Geothermal Wells: In addition to sending the form to
t the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount 1 �lr� 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 of Water Quality ality Revised Jan.2013