GW1--00055_Well Construction - GW1_20231218

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.W Contractor Information:Information:
14,WATER ZONES
W onhactor Name OM TO DESCRIP ION
Lice 5 f— G 14'�'� 1Gft
ft. ft. {
NC Well Contractor Certification Number 15.,OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name V ft. fro ft q . in. SOa11)6 pv
16.INNER CASING OR TUBING(geothermal closed-loop) i/
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le UIC,County,State,Variance,etc.) ft. R hi.
ft3.Well Use(check well use): m
Water Supply Well: 17.SCREEN 1
FROM TO DIAMETER; SLOT SIZE THICKNESS MATERIAL
I Agricultural unicipal/Public ft ft. in.'
•
Ir Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) R, ft in.
11 IndustrialCommercial DResidential Water Supply(shared) 18.GROUT
Irrigation PROM TO MATERIAL EMPLACEMENT OD&AMOUNT
Non-Water Supply Well: 0 fc ft Pate(D V MOM,
I:Monitoring Recovery ft ft
Injection Well:
ft. ft.
li Aquifer Recharge I Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)•
I l•Aquifer Storage and Recovery QSalinity Barrier, FROM TO MATERIAL EMPLACEMENT METHOD
II Aquifer Test IJStormwater Drainage ft ft
II Experimental Technology EDSubsidence Control ft ft.
III Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
I Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(ram,hardness,soi0roek type Qrara sae etc.)
/ / ft ft.
4.Date Well(s)Completed: I I/1_=l Wen D3# ft. ft
ft. ft ,, - ',,, -.+ ,•'5a.Well Location:
Rubi Meli LLC ft ft f j 1 4"'+
Facility/Owner Name Facility Mt/(if applicable) ft. ft "• t• rj 2021
3523 Red Mountain Rd Rougemont NC 27572 ft. ft. in,or,--r :-,;) .,,.,,,,_ ,
Physical Address,City,and Zip ft ft D WQJp ` "'d i-41
Durham 21.REMARKS � II,
County Parcel Identification No.(PIN) bj�l `'t f>. c Poem 1- ` _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: CASe./' it�
(if well field,one lat/long is sufficient) 22.Certification: •
N W 3
6.Is(are)the wells) a ermanent or Temporary Signature of Certified Well Contractor� ate
"'t
p� BY signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: tf�" or DNo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repay,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 pagee'to provide additional well site details or well
construction,only 1 GT-1 is needed. Indicate TOTAL NUMBER of wells construction details.You may also attach additional pages if nefeccary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J v'O (a-) 24a.For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths ifdi,(jerent(example-3@200'and 2@100') construction to the following: }'
10.Static water level below top of casing: ar C (ft-) Division of Water Resources,Information Processing Unit,
Ifwater level it above casing use•'+' a 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: G (m) 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: i construction to the following:
(ie.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 11 Method of test: 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
13b.Disinfection type: 14+0- Amount: " completion of well construction tei 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