GW1--03337_Well Construction - GW1_20230516

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well ContracorName
to/11 FROM TO DESCRIPTION
'15-ft, t t'?l�ft. fv
I 0_<ft. /eft. ® �
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
ft. I Qg ft. I b P4 in. 1 540/2,_2 6PG/&
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#• - 30 W) FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)M icipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
IndustriaUCommercial [3Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Oft. 8 ft. jig"h( f
G/�L "C' rr
Monitoring Recovery
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
__ 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage
Experimental Technology E3Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) l Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiUmck type,gruin size etc.)
0 ft. ft. v d `
4.Date Well(s)Completed: W"20-23 Well ID# ft. 7ZI ft.
e.1,�,1 f
Sa.WellQLocation: y ft. ft' /C
CX fL� ft. ft. c:r - a
ao; .>
Facility/Owner Name Facility ID#(if applicable) ft. ft.
MAY 1 G 2023
Physical Address,City,and Zip ft. ft.
J y 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification-
Lit) !
L8i9 N - 7r�. �►� 37` W 4��Zz
-zo' z3
6.Is(are)the well(s) ermanent or Temporary Si ature of Certi ed a ctor 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: QYes or Ca<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 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: I sae) (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@100D construction to the following:
10.Static water level below top of rasing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1
11.Borehole diameter: (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: F1 ,),-T i!1 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) 2-0 Method of test: _&Oy J ag 2 ),i 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: Id 1H Amount: 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