GW1--03131_Well Construction - GW1_20240522

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WELL CONSTRUCTION RECORD (GW-I) For Internal Use Only:
1.Well Contr ctor Information:
8/ Cil IVi /tl'`CHI $G/7 14.WATER ZONES
Well Contract✓✓�,orName FROM TO I DE RiP ION
a 7 94 A 7�G ft. 2c� ft. s 9/A.,),t.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Wizards Inc FROM TO DIAj/1ETER THICKNESS � MA'1E
Company Name 0ft. `Yia ft. co in.
{e 9"l ,
16.1NNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM O DIAMETER TH KNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) G ft. & 0 ft. li in. .2 4' ,PI"(.
3.Well Use(check well use): ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMun'cipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) Ofesidential Water Supply(single) ft I. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation goOM TO r MATE LL/ E. PLACEMENTMETHOD OUNT
Non-Water Supply Well: ft O rai 7 14v, /Lli/- 3 co f
Monitoring JRecovery ft. ft.
Injection Well: ti
ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type grain size,etc.)
ft.
7 j� l l ft.
4.Date Well(s)Completed: S(/.-2627 Well ID# I`\ - 1 25 ft• ft- ,,, , . t •' ?._,
5a.Well Location' ft
M, Po >� /e" ; ft. ft MAY 3 's [G4
Ft cility/Owner Name
//d�U /� Leg'
i #(if applicable) k ft ;t _ r
24 Coil( `ie'I Leg'Facility
ft. ft _... ._ .
P ical Address,City,and Zip pft. ft
Fj_... MANCS
County ParccelIdentification No.(PIN) �/ / 4� ��'< r ���� � 1�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �� , rt.,S • ei_A
(if well field,one 1at/long is sufficient) 22.Ce • nowN W S 6-2e2
6.Is(are)the well(s) Permanent or Temporary
Signature ol'Certified Wet ontractor Date
By signing this form,I hereby cert�that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: es Or DNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construct tnformatlon 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: 32 c (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@r200'and 2@100') construction to the following:
10.Static water level below top of casing: o (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: /+n (in.) 24b.For Injection 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: RC 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
13a.Yield(gpm) Method of test: Ptin►,r 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:C 6/Ctt p Amount: 2 (cif completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016