GW1--03954_Well Construction - GW1_20230612

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES ry
Well Contractor Name FROM TO _ DESCRIPTION
,. "f ,• ft. ft. s
`ei 5 i b.� ft. i
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a livable
.Water Wizards Inc M TO DIAMETER THICKNESS RIAL
ft. ". in. ,,7
Company Name 16.INNER CASING OR TUBING(geothermal closed-moo
2.Well Construction Permit#: 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 Xesid
Ipal/Public O ft. tt. in.
Geothermal(Heating/Cooling Supply) i ntial Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM I TO- AT AL EMPLACEME METH D I AMOUNT
Non-Water Supply Well: ft. ft. •I '.�d ;
Monitoring Recovery
Injection Well:
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) lTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(HeatinglCooling Return) _ Other(explain under#21 Remarks) FROM ft.. To ft. DESCRIPTION(color,hardness soil/mck t in sim,etc.)
_
4.Date Well(s)Completed: L ~�°� Well ID# tt. ft. r---
5a.Well Location:
Facility/Owner Name Facility ID#(if applicable) ft. ft. 2 J
1� } (�,(� ft. ft. InE�fir,a ion?rt"-C
Physical Address,City,and Zip
t
0tt�.C.s 4'� r 21 REMARKS
ItCounty / Parcel Identification No.(PIN)1t ' & ` . .Al
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �• i r ,
(if well field,one lat/long is sufficient) 22.Certification: ".
6.Is(are)the well(s) Permanent or IOTemporary Signa a of Certified Well Contactor ' ✓ Date
By signing this form,I hereby certify that the well(,)was(were)constructed in accordance
7.Is this a repair to an existing well: nes or [:)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out;mown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remark 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
f
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-3@200'and 2Q100') Construction t0 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: ' (in.) 24b.For Infection 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: 1 T construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) u`:�� Method of test: ,/ 24c.For Water Supply&Iniection Wells: In addition to sending the form to
n, the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1 Amount: �` V��t�'- 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