GW1--05953_Well Construction - GW1_20230912

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
SO aP
�� 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
302H _* 260s11. Z70t• 1,1 16077
35-oft. 3�� 2/ 6,00in
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased'wells)OR LINER(if ap licable)
Water Wizards Inc FROM TO DIAMETER' THICKNESS MATERIAL
Company Name 0 ft. Sy)ft. a /' in. 3/lye r�� d9 C 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. : in.
17.SCREWater Supply Well: FROMN TO DIAMETER SLOT SIZE THICKNESS MATERIAL
®Agricultural ['Municipal/Public 0 ft• ft. is
N Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
$Industrial/Commercial OResidential Water Supply(shared) 18.GROUT - . . -
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: 0 ft. ysft. 3/4➢I t5//C JO ft, 200IhS if�-4' '.l
®Monitoring ['Recovery ft. ft. /(
Injection Well: l ) /
®Aquifer Recharge ['Groundwater Remediation ® rt. 5-0 ft. /1°��--!C Gam%- 'C�,/
19.SAND/GRAVEL PACK(if applicable)
$;Aquifer Storage and Recovery ['Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
$Aquifer Test I['Stormwater Drainage ft. ft. ,
Il Experimental Technology (['Subsidence Control ft. ft.
®Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
$Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTIOJN(color,hardness soil/rock type,grain sa,etc.)
,h ft. .7 ft. D ye(vi,Z(
4.Date Well(s)Completed: g-10"-23 Well ID# / ft. 210 ft. .5 L! f � `& kf
Sa.Well Location: 7-0 ft. WV. Lt/'w` rtIr
J®SGl / ft. ft. G� e �._)
Facility/Owner Name Facility ID#(if applicable) ft. ft.
7( / L-1 Usys,JVic dx4,-41 M. ft. ft. SEP 1 2 2023
Physical Address,City,and Zip ft. ft. lnforR Jc n?rr»StF .uraa
3 �, 21.REMARKS l3�l+l�/.."'.JLa
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h C. ,Lt: J- or t
County Parcel Identification No.(PIN) I��/ / C j^'1t. 14
5b.Latitude and longitude degrees/minutes/seconds or decimal degrees: j�LI iN c LI 7
ngre in egrees/
(if well field,one lat/long is sufficient) 22.Certification:
•
3 °2 '4/O. W' N 78°.361 �'3. 71' W qe, ( 502ii,/ 6-/o-2-56.Ls(are)the well(s) rmanent or ['Temporarya of Certified Well Contractor Date
� By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
1=fl`�
7.Is this a repair to an existing well: N Yes or with ISA NCAC 02C.0100 or ISA 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: LIOC) (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to 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: &ellZ (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: eli r above,also submit one copy of this form within 30 days of completion of well
f N./ construction to the following: 1
(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) 15 Method of test: I DbeJYI Wil'Nkit For Water Supply&Injection Wells: In addition to sending the form to
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the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1 y/T 1 FI Amount: /K Olt»e et,. completion of well construction to ithe county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016