GW1--03332_Well Construction - GW1_20230516

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
[t. /D ft. w t^�n
-T
NC Well Contractor Certification Number 15.OUTER CASING forulti-cased wells)OR LINER(ifap livable
m
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 ft. ft. I &,b in. ge-
16.1NNER CASING OR TUBING eother al closed-too
2.Well Construction Permit#: r f'1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.111C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. is
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DI M nicipal/Public 0 ft. ft. in.
f- Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
lndustriat/Commercial L i Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMEriT METHOD&AMOUNT
Non-Water Supply Well: ft. eq ft. 3 tl O/,C ,-&J 0-0 l(D5
Monitoring ORecovery ft, tt. WW1 0 �S
Injection Well:
_ ft. ft.
Aquifer Recharge nGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
:)Aquifer Test DStormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) 'Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ! Other(explain under#21 Remarks) FROM TO DESCRIPTION color,/hardness,so0%ock type,grain sire,etc
O ft. ft. OtJCT ia/
4.Date Well(s)Completed: 11 ID# [t. f ft. r—�L
Sa.Well Location: ft. ciz ft.
2 ft. ft.
1 C CrJ l�J •U47't,t'_�
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ft. ft. UL e t•i
r
Physical Address,City,and Zip � - -- MAY q
% 21.REMARKS 1
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: C 4.d Or
(if w2 well field,one lat/long is sufficient) c� 22.Certificatipn:
aCcto,Jf�cp '� Ji3 � N I� ��03C� � W 'C/,-?
6.Is(are)the well(s)�rrmnent or Temporary Signat re of CertifiedDate
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: 0Yes or Q o 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 thus 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: dL/ (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
9
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
n above, also submit one copy of this form within 30 days of completion of well
12.Well constriction method: 9c[>k+'l.r 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 best: 26,—!A24c.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: Amount: 01A�11 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