GW1--03040_Well Construction - GW1_20240520

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
11Ja-C.11- TR.thiNA=.S 0 I\,1 14.WATER ZONES
Well Contractor Name FROM TO i DESCRIPTION
Li S 1 ' C ft. ft.
ft ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a • ble)
Water Wizards Inc FROM TO 1 DIAMETERE THICKNESS MATERIAL
CompanyName O ft. 14^ f (9I/'! in. 5PILZ% (PVC.
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 1O'
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural CIMunicipal/Public ft. ft. Is.
Geothermal(Heating/Cooling Supply) Vesidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared)
1&GROUT
Irrigation PROM TO i MATERIAL t EMPLACEMENT METHOD&AMOUNT
LNon-Water Supply Well: ft. ftI (Monitoring DRecovery it ft.
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach adBtlo°al sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,luvdaess soil/reek type gaffe size etc.)
ft. ft.
4.Date Well(s)Completed:5 . - 1 Well ID# ft. ft. `•.'�,r i, 1. ; �,.
5a.Well Location: ft. ft. MAY 2 0 2024
Jv rrr1Es iDwxN S ft. ft.
Facility/Owner Name Facility lD#(if applicable) ft ft )- I;„)4
35(2 a J o OSIZ O, ft. ft c t.C.11,`;,;
Physical Address,City,and Zip ft ft.
Ca PA lV✓J LL C 21.REMARKS
County I Parcel Identification No.(PIN) 6 E P D JOT GanIS T it Tucr 1 HS 4,J6s.L.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 61 WI FCR FNFoi2MA'17414AI P'4?)ecE CIML({
(if well field,one lat./long is sufficient) 22.Certification:
36. )034091 N -..-I$a 10°11610 LI w A/004 S • 6- ALI
'6.Is(are)the well(s)3ermanent or Temporary Signature of Certile,A;cd&il Contractor Date
By signing this form,I hereby certifr that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: f Yes or f No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out knower+sell construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells constnution details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: t2 t:2.0 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdtfferent(example-3@200'and2@100') construction to the following:
10.Static water level below top of casing: 3(t, (ft-) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 /$' (in.) 24b.For Injection Wells: In addition to sending the fort to the address in 24a
12.Well construction method: IQ07ARLi above,also submit one copy of this form within 30 days of completion of well
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
f�
13a.Yield(gpm) S Method of teat: ! M? 24c.For Water Supply&Iniection 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: H/T N Amount: '0 01. 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 2-22-20I6