HomeMy WebLinkAboutWELL-01-2018-094128.TIF WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
2ECE1V EC
' - ' 1.well Contractor Information:
Michael W. Shaw 7f11& u.\YAreaZONES
APP 2 3 FROM , 5o DESCRIPTION
Well Contractor Name �TI/ f, 1
-3232 �Q
NC Well Contractor Ceniticai ion Number VC{ir{4`/�U~ `UUi'fl ft. rt.
Advanced Well Drilling,L1LCNMENTAL HEALTH FROM TER CASING(for ma IETERsed eIIs)OR THICKNLINER ESS op Helaine)MATERIAL
0 H. g--7a B in. Heavy PVC
Company Name 16.INNER CASING OR TUBLNG(geothermal closed-loop)
�yFROM TO DIAMETER THICKNESS MATERIAL Well Construction Permit g: 1�Zo -074//7. ft. rt. In.
Um all applicable well construction permits(i.e.Couny,Stale,Variance.etc.)
ft. ft. In.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATER/AL
°Agricultural OMunicipal/Public ft. R. in.
°Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) n. H. in.
°Industrial/Commercial °Residential Water Supply(shared) Ie.GROUT
FROM TO MATERIAL EMPLACEMENT METHODS AMOUNT
❑IrieadnD e) R. 26 It. Bentonite Poured
Non-Water Supply Well:
°Monitoring DRecoveO ft. O.
Injection Well: ft. ft
°Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
°Aquifer Storage and Recovery °Sahnip'Bamer FROM TO MATERIAL F.MPL\CF.DIENTMET110D
ft. ft.
°Aquifer Test OStormwater Drainage
°Experimental Technology OSubsidence Control It. R
°Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets If necessary)
FROM TO DESCRIPTION(eeler.heniens.soil/ruck nye grain she.etc)
°Geothermal(Heating/Cooling Return) °011ier(explain under#21 Remarks) D it `�-2 II. I cr
4.Date Well(s)Completed:lb i 7` s'ell ID# ft.'7' �f/�.t, rya -'n Po li�
fL y �,.k
Sa.Well Location:
�yf /.� arc
J 1 , a We is ,Ys It. J/f fir. bray pvcC
A ft. / J ft. �J M1 -
Facility/Owner Name Facility ID:(if applicable)
ft. ft.
gTrre itionth (d ynSLSr'�OL O ft. ft.
Physical Ad Circ and Z" r v
N 4/o� Q/ 21.REMARKS
County PaTcei Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well geld.one lllaaullfoonng las nicient) 22.Ceti adan:
71O051-5-
Ad iV i/ /�2 :V \\r 1/ �
6r • d Signature of Cenified Well Contractor DaR
6.Is(are)the well(s): °Permanent r OTempo tib
Br signing this firma./hereby cerfr that the nal//.9 wras(were)constructed in accordance
wldi 154 NCO('02C 0100 or ISA,VCAC 02C.0200 Well Construction Siaadards and that a
7.Is this a repair to an existing well: °Yes or No copy of this record has been prided to rhe well curer.
If this is a repair,fill out drown nail construction it formation and plain the nature of Me
repair ander 021 ensarks section az-an the hark of thisfarm,, 23.Site diagram or additional well details:
1 You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
Far maniple injection or non-stater supply Ire//s ONLY with the some construction,Ino can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: /q r (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Fur multiple wells list all depths(Idffererts(crumple-da?00'and?ad00
/_ ) construction to the following:
Gg
10.Static water level below top of casing: 0 (ft.) Division of Water Quality,Information Processing Unit,
If Hater level is above casing,use^-^ 1617 Mail Senice Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 6 (in,) 24b. For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Pik' /� ✓y
�'1(� Da��I s ' above. also submit a copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push.etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WE 19 ONLY: 1636 Mail Service Center,Raleigh.NC 27699-1636
13o.Yield(gpm) a(�'/ Method of test: Air 24c.For Water Supply&Infection Wells: In addition to sending the form to
HTH / /J die address(es) above, also submit one copy of this form within 30 days of
completion of will construction to the county health department of the county
136.Disinfection type: Amount: //
where constructed.
Form GW-1 North Carolina Depanmeat of Environment and Natural Resources-Division of Water Quality
Revised In 2013