GW1--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