GW1--03138_Well Construction - GW1_20240522

Print Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contr tor Information:
lGl� c V p ft I'r(/'/1'1)L/1 114.WATER ZONES
Well Contractor ame FROM TO DESCRIPTION
2767 /1 110 ft- 112 ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap,,t-;cable)
Water Wizards Inc FROM TQ c� , DIAMETER t� TNICXN SS MATERIAL
0 it.Company Name /b IJVn l(yli/,• G ��C
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIA.M TER T CKNESS RI�11.
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ' ft.
qGft• V is X_ 7 G
3.Well Use(check well use): in. X!!�t
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural rcipal/Public ft. ft, in.
Geothermal(Heating/Cooling Supply) ffResidential Water Supply(single) ft. ft- in.
Industrial/Commercial DResidential Water Supply(shared) 111.GROUT
Irrigation FROM t TO i MATE 1 L EMPLACEMENT METHOD AMOUNT
Non-Water Supply Well: tY ft. qc ft. pf;/I1V"t/' pow— ?Oc '0 1
Monitoring DRecovery ft. —/ ft./
injection Well:
ft. ft.
Aquifer Recharge QGroundwater 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 QSubsidence 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. ft.
�f-/0.2 2 P 3a- 02k 9 ft. ,t `.
4.Date Wells)Completed: e!1 ID#
5a.Well Locatio ft. ft. MAY 2 1 -62 4
(o<oil iit►�a� ft.
ft. ft
Facility/ ner Name tyID ifappl' able) C' ;9q i l/ ( / d /LJ4 / j ft. ft.
PhysicalAddresl,City,and Zip
ff. ft.
ppi1^Gh 21-RE AilI/s /i //
County Parcel Identification No.(PIN) ` /! fll/i, J.f,"71 ge J'+' ici c�/a
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r hQG' / 70
(if well field,one lat/long is sufficient) 22.Ce cad
N W 9:-'/ ' /�•
6.Is(are)the well(s) Permanent or Temporary gnature of Certifi e or Date v�
By signing this form,1 hereby certi that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: WK.;or ONo with I SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known NO 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 UMBER of wells construction details. You may also attach additional pages if necessary.
drilled:9.Total well depth below land surface: / Vc SUBMITTAL INSTRUCTIONS
(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@ l00') construction to the following:
10.Static water level below top of casing: 3 0 (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: �f (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: A_! Cri y construction to the following:
(i.c.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Ci/AP 24c.For Water Supply&Injection Wells: In addition to sending the form to
r the address(es) above, also submit one copy of this form within 30 days of
-13b.Disinfection type: _.•^ Amount:_214) completion of well construction to the county health department of the county
where constructed.
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016