GW1--03338_Well Construction - GW1_20230516

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
woc niw) 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
NI ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if ap livable)
Water Wizards Inc FROM TO DIA R THICKNESS MATERI L
ft. C16
ft. in. � /`�/
Company Name '16.INNER CASING OR TUBING eothermal losed-loop)
V'r�
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) O ft. ft. in. E �I t�
3.Well Use(check well use): ft. ft. in. I
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
:)industrial/commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. -71 ft-
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
l7lGeothermal(Heating/Cooling Return) Omer(explain under#21 Remarks) FROM ft. TO ft. DESCRIPTION(color,hardness,sollfrock type,grain size etc.)
4.Date Well(s)Completed: 9 Well ID# ft. ft.
Sa.Well Location: ft
. ft.
�p -
Facility/Owner Name I ' Facility ID#(if applicable) ft. ft.
152 USIIJ 15 nifog-A ft. ft.
Physical Address,City,and Zip ft. ft.
C „(Jl��1 V r l 1 I R 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:
(6• 16u31 N �g, W
6.Is(are)the well(s) Permanent or Temporary Signature of CeE2 .0100
Contractor Date
By signing thisereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or ONo with 15A NCAC or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fiill out known well constructs information and explain the nature of the copy ofthis recen 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 ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 81 A) 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: A) 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: (�j}�},�t� 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) Z Method of test art 19 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:_)-JJH Amount: _ l -<8 Z/ 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