GW1--03136_Well Construction - GW1_20240522

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.We Contractor Information:
1 {�-(.e _ c� ejld 114.WATER ZONES
Well����CJoJJJwactVVor��Na__m`e�-�� FROM TO I DESCRIPTION
Llgh 4' C mod: v 'aft- 1vp,
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a licable)
Water Wizards Inc FROM TO DIAMETER THICKNESS PVC
Company Name 0 it. 4;(? ft. I in- cy^� G
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. is
3.Well Use(check well use): ft. ft is
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM ' TO t MATERIAL ' EMPLACEMENT M OD&AMOUNT
Non-Water Supply Well: U ft-
�7 ft- pd p , /' 5( -
Monitoring ID ecovery R tt
Injection Welt ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM r0 MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage rt. rt.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
eothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,pate etc.)
G
ft. ft.
4.Date Well(s)Completed: 8,-‘......- 2T 1 Well lDli r I60 w 2..r. .. ft • 4, s...t %•
5a.Well Location: MAY 2 :, C014
Facility/Owner Name Facility 1Dtt(if applicable) ft• ft
II.`':.:.,
Log po kc mote Or. ft. R. r; : 7•_..3
Physical Address,City,and Zip ft. ft
i1. 21.REMARKS ,,�/�County Parcel Identification No.(PIN) _rh,.5 t it 1�n4 `� I f f .
/
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: e.
(if elll�fiel(d,/onne/latt//llong is sufficient) L/ ` /, 22.Certification:
K.CTc1t1D 7 ( N '�7D . /'7V 3 /ha W ( ////�/
.J
6.Is(are)the well(s)f Yef�anent or Temporary Signature of Certified Well Contractor Date"
��� Sr signing this form,I hereby cert(that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: at" or ONO with 15A NCAC 02C.0100 or 1 SA 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 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: AlG]0 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if-Afferent(example-3@200'and 100') construction to the following:
10.Static water level below top of casing: 9" (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"++" f 1617 Mail Service Center,Raleigh,NC 27699-1617
611.Borehole diameter: 4 (in.) 24b.For Iniectroa Wells: 1n addition to sending the form to the address in 24a
e04,01 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
t Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) _0 Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
�� " 4 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: ______ 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