GW1--01410_Well Construction - GW1_20240301

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contra or Information:
1V,J/ , ,
g/c.„4 ell • r 1]r,,7./h I/h =F G 14.WATER+ZONES S ;,t:; - ^.: ;
OM
Well Contractors Name J ft TO DESCRH'TION
Z�q/(/ � 'C ft. / ft. / 1' i. 'e
NC Well Contractor Certification Number ,15 OUTER:CASING.(for multi-casedii411)"OR LINER(if air tieeble)=" ,
Water Wizards Inc FROM TO DI7 ETER. THICKNESS MATIRIAL
U ft. 6ft. �p : 'in. c �i /
Company Name ]�
16.INNER CASINGOR'TUBING(geothermal closed-loop)'''* i-e, "` '
2.Well Construction Permit#: FROM TO D Tw S
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft S ft- Tr in. ( VC pz
3.Well Use(check well use): fL fL is G!/
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0 - .icipal/Public ft ft. in..
Geothermal(Heating/Cooling Supply) J 4 Residential Water Supply(single) ft. ft. is
Industrial/CommercialEDResidential Water Supply(shared) ► } F nr q►
Irrigation
E
Non-Water Supply Well: TO "f v� ri p I/ F U//ff.^r�y� p AMOUNT
Monitoring Recovery ft. ftjj t
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation l'% V ft.
-19:SAND/GRAVEL PACK(if applicable) ' ,,
'Aquifer Storage and Recovery oSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft. i
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer -20;DRILLING LOG(attach,addltionol'sheets if necessary),-• . , =
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM ft. TO DESCRIPTION(color,hardness,soWrock type,grain size,etc.)
4.Date Well(s)Completed:2`J r-267 ell m# ft. ft.
SSn. II Location R R j i-a -'( .1
1i1,•t �t°/�J /J ft. ft. MAN
. t !l �
Facility/Owner Name / acility IDit(if licable) ft. ft. 1 IV),A K 0 1
zn?4
211 2 V tyrGn )/L i i
G 10T-er [t. ft.
tn,`'.�rrrta•,� ;m x .a
Physical Address,City,and Zip �0�� ,
s
Wei 10
County Parcel Identification No.(PIN) 5((/' K / /�� �i/I?7 (.f�j�,n ��/ 'c
fib.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ical/&7 7/ R !Co)C.ei
(if well field,one tat/long is sufficient) 22.Ce ' o
,1
N W - 5,--m l
6.Is(are)the well(s)fir.'ermaneut or EDT•..i.orary Signature of C ctor Date 1/
By signing this form,I hereby certify that the na il(s)was(were)constructed in accordance
7.Is this a repair to an existing well: I)I es or ONo with i5A NCAC 02C.0100 or 154 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 1to 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: f/ SUBMITTAL INSTRUCTIONS II'0 U i
9.Total well depth below land surface: ( ) 24a. For All Wells: Submit this i form within 30 days of completion of well
For multiple wells list all depths 11-different(example-3 00'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 caring use'+' 1617 Mail Service C i nter,.Raleigh,NC 27699-1617
11.Borehole diameter: 0 (in) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
/1 // above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following: 1
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUP Y WPLLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) _ ethod of test: /, ,,/'A 24c.For Water Supply&Iniection Wells: In addition to sending the form to
ie the address(es) above, also submi. one copy of this form within 30 days of
13b.Disinfection type: , /-/i0 Amount: '2 ((se c 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 1 Revised 2-22-2016