GW1--03966_Well Construction - GW1_20230612

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Water Wizards Inc 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
T 31 ft. �j3 ft
Taylor Often m
ft ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if applicable)
4497-C FROM I TO DIAMETER THICKNESS MATERIAL
ft ft t in.
Company Name 16.INNER CASING OR TUBING thermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICENESS MATERIAL
List all applicable well construction permits(i e.UIC,County,State,Variance,etc.) ft ( q ft in.
3.Well Use(check well use): R' ft in.
Water Supply Well: 17.SCREEN
� FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
_Agricultural El unicipal/Public f. ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) [t ft. in
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irri ation FROM I TO MA RIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft It.
t7(7 10- V \.k'-C.L(
Monitoring EIRecovery ft. ft.
Injection Well:
ft ttt.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft ft
!- Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) rITracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal Heating/Cooling Return Other(explain under#21 Remarks) FROM ft ft TO DESCRIPTION color,hardness,so Vr k type,grain ds etc
4.Date Well(s)Completed: K-26-23 Well ID# R' ft. n t= I"'` f^"
5a..Well Location: ` ft ft t 14 L_%a i V A—
Lop
A.Cu 4\& �( C]e — ft It. N
Facility/04vner Name nn Facility ID#(if applicable) t ft f
lm
ry en `r1le.A VW lit. n>c-Cord fL ft. .
Physical Address,City,and Zip ft. R'
00 1 I l� 21.REMARKS
/7
County �J 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—
N -T$Z 711 (D -7 W
6.Is(are)the well(s) Permanent or OTentporary Signature of Certified a trac or Date
By signing this for ,I reby certi(y that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or QNo with 15A NCAC 0 C 100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,,fill out known well constructon information and explain the nature of the copy of this record as 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: 2SV (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: to (M) 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: 1 Gl (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
� u above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: I � t�, A�I 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: AAMP 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
1 13b.Disinfection type: / Amount: ID 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