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HomeMy WebLinkAboutGW1--03451_Well Construction - GW1_20230516 WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1.Well Contractor Information: 10411 Icy �CV-11 14.WATER ZONES Well Contractor Name G FROM TO DESCRIPTION It 10 O NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if a licable) Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL in. A'1J Company Name l/ 't' 1 16.INNER CASING OR TUBING(geothermal closed-loop) 2.Well Construction Permit#• FROM TO DIAMETER THICKNESS I MATERIAL List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft. S ft, j, in. -7t n Gl� PUC 3.Well Use(check well use): ft. ft. i Water Supply Well: 17.SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL Agricultural [:)Municipal/Public 0 ft. ft. in. Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in. Industrial/Commercial DResidential Water Supply(shared) 18.GROUT Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: 0 ft. It. Monitoring IDRecovery ft. ft. Injection Well: ft. ft. Aquifer Recharge n Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) Aquifer Storage and Recovery Q Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD Aquifer Test OStormwater Drainage Experimental Technology Subsidence Control Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary) Geothermal(Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardn soil/rock t n size etc ft. ft. 4.Date Well(s)Completed: N-C-23 Well ID# ft. ft - i Sa.Well Location: dr�I L cam,�/� ft. ft. Sy1u 1G'V�C` I,�iY�OVI t ft. ft. 1 v luzi Facility/Owner Name Facility ID#(ifapplicable) ft. R L-LA W Gi f f �� Physical Address,City,and Zip 9�r �1Z- j2 � 21.REMARKS County(' J l J' , Parcel Identification No.(PIN) t 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one lat/long is sufficient) 22.Certification: 6.Is(are)the well(s)17Permanent or [:)Temporary Signature of Certifi ontractor Date r� By signing this f m hereby certify that the well(s)was(were)constructed in accordance 7.Is this a repair to an existing well: JJ Yes or ONo with 15A NCAC .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: /14(/ (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 11.Borehole diameter: lJ Vq (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) tJ Method of test: P v 24c.For Water Supply&Iniection 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: H 7rl Amount: Z completion of well construction td 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