GW1--03339_Well Construction - GW1_20230516

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
Cl G`1 b G G ft. ` ft. tr
ft. I ft.
NC Well Contractor Certification Number IS.OUTER CASING for multi-cased wells)OR LINER if a livable
RI
Water Wizards Inc FROM TO DIAMETER THICKNESS MA AL
ft. ' ft. in. ®&' Q
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell construction permits(i.e.UIC,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 [DMunicipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irri ation FROM I TO TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply We
Monitoring 9<11coery ft. ft.
Injection Well:
ft, ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) E3Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM ft. To ft. DESCRIPTION color,hardness,soiltrack type,gmin stm,etc.
4.Date Well(s)Completed:(4 Well ID# ft. ft.
ft. ft. �_'4
5a.Well Location: i
Facility/ /der Name Facility
,AID9(if
applicable) ` ft. ft.
(l ✓T 1�� 6TV/YmY I rl l�b�-"�t'�5� ��V ft. fLIr
l:f i
Physical Address,City,and API-1
rDG.T/ 21.REMARKS
10��1l ( ` , d
County Parcel Identification No.(PIN)
t`
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ��' �
AAZ
(ifwell field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s) Eetrmanent or IDTemporary Sgndture of CertifreTWell Contractor Dafe
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an eaasting well: es or nNo with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 lVell 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 tinder#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: " (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2 a 100) construction to the following:
10.Static water level below top of casing: r (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: 64 (in.) 24b.For Injection 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) Method of test: 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this forth within 30 days of
13b.Disinfection type: Amount: kdo-�) completion of well construction to 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