_Well Construction - GW1_20230315 (12)

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
N:CC1!L rJ pj �s'�`J 14.WATER ZONES
Well Contractor Name - FROM TO DESCRIPTION
yS78'- L �� F. I�� Ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licsbk
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
O It. O ft. in. 4+ u v
0 i
Company Name 16.INNER CASING OR TUBING thermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. n. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipaUPublic 0 ft. n. in.
Geothermal(Heating/Cooling Supply) S Residential Water Supply(single) ft.
Industrial/Commercial QResidential Water Supply(shared) 18.GROUT
Irrigation FROM I TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: © ft. n. ■ 1
Monitoring Recovery �V
Injection Well:
Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery QSalinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test QStorrnwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. n.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) r3Other(explain under#21 Remarks) FROM n. TO DESCRIPTION color,hardness,wfVmck type,grain size,etea
ft.
4.Date Well(s)Completed: Well ID# 7 ft. rt.
5a.Well Location:
C 19s E ►'�'1 1 1 S n. n.
Facility/Owner N e Facility ID#(if applicable) n. ft.
y0 M0,ZT=M ESTP,tes EZ0, ft. ft.
Physical Address,City,and Zip ft. ft.
pe,'L 5 0M 1 21.REMARKS f�
County Parcel Identification No.(PIN) S L 6N LT t-J 'r0 CLATOFF
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: cm. xmls'
(if well field,one[at/long is sufficient) 22.Certification:
1(0 3°1TT3LN —�Y, gg�sys3 W MIt
6.Is(are)the well(s)OV;rmanent or Temporary Signature of Certi¢ d Well Contractor Date
By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: M• s or QNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 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 to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: V o (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200 and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
t
11.Borehole diameter:_ (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
i2���, l above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: N construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
A
13a.Yield(gpm) Method of test: / aftwo 24c.For Water Supply&Injection Wells: In addition to sending the form to
�+ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: L41 Amount: —1 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016