GW1--03447_Well Construction - GW1_20230516

i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Taylor Often 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
4497-C Oft. 63 ft.
ft• ft.
NC Well Contractor Certification Number IS.OUTER CASING for multi-cased wells)OR LINER if a licable
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
ft. Z ft. 1 in. (/`v � e1
Company Name 16.INNER CASING OR TUBING eothermal 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. Lr in- < N fJ
3.Well Use(check well use): tt. ft. in.
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural I3Municipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
11Ti anon FROM I TO MATERIAL.- EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O tt. D ft. f bi-KerA a jx lbS
Monitoring Recovery ft. ft.
Injection Well:
ft. It.
- Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test I]Stormwater Drainage • ft.
Experimental Technology Subsidence Control -
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessa `W
Geothermal Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soufmck type,gmin size,etc.
uu
4.Date Well(s)Completed: -1-21-Z ttI Well # t)�j ,1% ft. ft.
5a.Well Location: -
L;A v-'oua Cron
I ft. I 2023
Facility/Owner Name 11 Facili'ty�ID#(if applicable)
/�
�� tl f�� 10�If1$. 1►YV1�Pi1r�pF'C tt. tt. :'
„� ;`•^..�,>::r� l:Ri
I fl4Gial i
Physical Address,City,and Zip - - ft. tt. vA w"4S'
O ,-
Res C O n 21.REMARKS
County 1 Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one llatflong is sufficient) p 22.Certir'Ication:
�• J✓07� N �S�. O W
6.Is(are)the well(s) Permanent or Temporary Signature of Certified a on ctor Date
TTT By signing this for / ereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or [:)No with 15A NCAC 02 100 or 15A NCAC 02C.0200 Well Construction Standards and that a
1f this is a repair,fill out known well canstructio r information and explain the nature of the copy of this record been provided to the well owner.
repair under#21 remark section or on the back of this form.
23.Site diagram or additional well details:
S.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: (ft.) yqa, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if di ferent(example-3@200'an/d 2@I00') construction to the following:
v 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
11.Borehole diameter: f (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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
13a.Yield(gpm) Method of test: 24c.For Water Supply&Iniection Wells: In addition to sending the form to
C the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: M Amount: Z JOB completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016