GW1--06807_Well Construction - GW1_20231023

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
1.Well Contractor Information:
1.4.=WATER2ONES,:1:....:r` ;;,,.,';.lTIO .,., • ••,...:• .,..
FROM TO DESCRIPTION
Well Contractor Name A b rt. Sc) fr• JJ,,- 4/
c038 -A NO*. l6Qft. 101, . GAL
NC Well Contractor Ccn' lion Number t .?15:UUTLR,CASING.'(for tables+eased iVell i)OR'LlNER(ifnp`Letthler-:: ,:
/ �^�5/ 4a C - 'mil FROM T,OO DIAMETER: T/H�ICCI NFSS 15ATE`RIIAL •�
(L,Cdr 11 C• �Jk1 �l�q tt srJv4 fr. f�z in. iVICIZ.� 1�V�
Company Name q :16::7NNER.CASING':ORTUSTNG:rneottierrrinlAiii d-lon'
2.Wc11ConstructionPcrnhit#: l.�t�03 FROM TO nIAMETEI n�'" '"�
7lSICIWESS h7A7ERIAL•.
List all applicable weitconstrucllonpernths(i.e.County,State,Variance,etc.) ft. ft. do
3.Well Use(cheek well use): it. H. bw
`47.SCREEN -] ,..... :j,r )
Water Supply Well: FROM TO IUAME SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M icipal/Public ft. tr. in,
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) it, ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) t•.19;GROUT' a
❑hTigatioa FROM TO MATERIAL• E `• L CEhlENT hfETH0U 8 AhI0UNT•
Non"Water Supply Well. d tr. �� fr. /je ot.L�JJ �O C7 A L
❑Ivionitering ORecovery
Injection Well: It ft. Cc/+ied C4 Al-- T�
ft. •ft. �-a�`+
❑Aquifer Recharge ❑Groundwater Renrediation ..19::SAND/GRAVELMACK(ifariplicable)'i:•q =•;€ ..b.t.: .;•;•r.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO M1fATERIAL EMPLACEMENT METHOD,,
['Aquifer Test it: ft j
❑Stornhwater Drainage
❑Experimental Technology ❑Subsidence Control fr. tr.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLINGiI OG'•(oftudli'uadidannl sheets"itne ee9earv)'°•":', :r.• . _,;,;;::c
ha
FROM TO DESCRIPTION(col❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) or, rdness,salVrack type,grain size.MOp ft. �0 rr. dpm;� .
4.Date Well(s)Completed: S - ZIP.'2,6L3 �/t 0 ft. �O ft. l{/,0 � p_�`
sue. 'watt Location: �7 e)fr• �o� tr. �( /4.te-
6 F'►mok !1.rw ,�j ft Jr�g ft. c�
FneiGty/Owacr'Namc FacilirylDli(if applicable)
`''�it• /i a IG +(D�I� AC/
7a , Fri Po ,e -D�K6o1� fr. fr. L?' I 1: ,_„t r'"
L. ft. ft. .t,-.i ,L. !r. z.�
Physical Address,City,and Zip jjtt1��:111
,5-fapay cc, 3 V-oV- P21:ItE1VIARl(S:• u: ; yt ". l`tr:''h :i't: Li1C "
County Parcel Identification No.(PIN)
1 Ii t0r7 "..^.it t'r atew4): I F Sb.Latitude and Longitude in.degrees/minutes/seconds or decimal degrees: "'�;`='
(if well field,one lat/iong is sufficient)' 22.Certification:
iS
/J,%Z er-2-92.623
6.Is(are)the weli(s): �Ternianent or . ❑Temporaryc)1,4
r allure ofCertifed Well Contractor '"i Date ' •'
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑yam or igicO with 1SANCAC 02C.0100 or 15ANCAC 01C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature oldie copy of this record has been provided to the Well owner.
repair under 421 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.•Numbel•of wells constructed: O N.f__ You may use the back of this page to'.provide additional well site details or well
For,multiple injection or non-water supply wells ONLY wltu the some construction,you can constnletion details. You may also attach additional pages if necessary,
submit one foray. 24.Submittal Instructions: j
s
9.Total well depth below land surface: /too i i
For
trhrrlrlple melts list all depths ifd�crent(exaurple-3Q200'and 2 ldo ot) 24a. For All Wells: Submit this form within 30 days of completion of well
© ). construction to the following: I
Ill.Static water level below top of casing: e5 b •. (ft.) Division of Water Quality;Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mall Service Center,,Raleigh,NC 27699-1617 .
11.Borehole diameter: 47 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: o-fd.ry above, also submit a copy of this foim within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following: 1
I
13.FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,Underground Injection Control Program,
JJ A 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yieid(gpm) AJ Method of testy !C 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13b.Disinfection r�ry the address(es) above, also submit one copy of this form within 30 days of
type: i Avis(el Amount. f5 1t7� a completion of well construction to the county health department of the county
where constructed.
•
Fonn GW-1 North Carolina Department of Environment and Natural Resources—Divisidn of Water Quality
Revised Jan.2013
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