GW1--00025_Well Construction - GW1_20231218

Print Form 1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Contractor Information:
J r) 1"'r1 (044Un
14.WATER ZONES 1
Well Contractor Name FROM TO DESCRIPTION
30-2-1/ , 6.<n• tat) 2-��-011
f. ft. 1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap Ilcable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
CompanyName •
0 rt. t 0 ft. I/ " In. 5 .14 40 P ye-
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft ft i, in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
0Agricultural DM eipal/Public ft. ft. In.'
Ithermal
(Heating/Cooling Supply) - sidential Water Supply(single) • ftstrial/Commercial Residential Water Supply(shared) 18.GROUTation FROM TO MATER AL EMPLACEMENT METHOD&AMOONT
Water Supply Well: G tO Al&T 2$o(bs /�nitoring Recovery tt ft 3r ion Well: ft• �®" __ifer Recharge !rrotmdwaterRemediation 19.SAND/GRAVEL PACK(if applicable) �ifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ifer Test I[�Stormwater Drainage ft
erimental Technology Subsidence Control ft ft.themtal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
thermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPITON{color,hardness sai0roektype grain size etc.)
al
� '" D ft 7 n o✓tp'6i elLr'1
4.Date Well(s)Completed:i t' -2 3 Well ID# nr 1`` 2 2-(p 7 f 7J.5- ft G/C.y/s4401
5a.Well Location: 3S ft. ft.
to
G,etr a troth,. _, t i.. ` '
J MAAS (Oki s n. ft. `' f --�
Facility/Owner@ Name ` n Facility ID#(if applicable) ft. ft I v�.C j S
IXu&Q ®Id art 1\ e Q€9 �U'& e(b . c�(sf7( ft. ft I: 111:,1-4- ,^;, , ,._ �nC.
xphysical Address,City,and Zip ft. ft. DW L:.,.�0; •0 Ci
eirSe' 21.REMARKS '
County Parcel Identification No.(PIN) ♦/i, i/e4/ SD' 41--w-e. 4 ca.- ei'l 419.41
1.
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: M`) 'Q 75. '
(if well field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s) ermanent or Temporary of ed Well r Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: N Yes or IIIK with ISA NCAC 02C.0100 or ISA 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 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 1
9.Total well depth below land surface: I
P / D (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdtfferent(example-3 a@200'and 2@100) construction to the following:
10.Static water level below top of casing: 2 5 (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: iJ frg (m.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Q N above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: /�� f Y construction to the following: 1'
(i.e.auger,rotary,cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Cotter,Raleigh,NC 27699-1636
•
13a.Yield(gpm) 25 Method of test:giat.J A 216Lirs 24c.For Water Supply&Iniectiori Wells: In addition to sending the form to
/1�� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount 70 , completion of well construction to the county health department of the county
where constructed. '}
1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016