GW1--03306_Well Construction - GW1_20240603

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
6i--2L COL. 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
W
4 5 vs ft. &y ft. 3 GPM
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wel)OR LINER(if ap licable)
Water Wizards Inc FROM TO DIAMETER_ THICKNESS MATERIAL.
Company Name CD ft. .K1 it- ey a/'i n. 51)(2,2 1 V
P'p C
) INNER CASING OR TUBING(geothermal ccloseddoop)l
2.Well Construction Permit#: (j 1.1J r t'/''O9 G: 7 - oM TO DIAMETER 1 HIC KNESS 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. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
()Agricultural Municipal/Public ft. ft. in.
IJGeothermal(Heating/Cooling Supply) idential Water Supply(single) ft. ft. in.
Qlndustrial/Commercial ()Residential Water Supply(shared) 18,GROUT _
1Irrigation FROM TO MATERIAL EMPLACEMENT
' METHOD&AMOUNT
Non-Water Supply Well: vrut ! f. d(d�yJ Rx.“-�4 fu't� t.'1 °G�
°Monitoring Recovery ft. ft.
1900 l b s
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery Salinity Barrier FROM f0 MATERIAL EMPLACEMENT METHOD
QAquifer Test DStormwater Drainage ft. ft.
BExperimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DFSCional N(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) (QOther(explain under#21 Remarks) ft 7 6 ft O a J CIa
4.Date Well(s)Completed: 3-i 3--� / Well ID# A 110 76- ft. 3cx� ft. 1�7 2000 L
5a.Well Location: R. ft.
ft. ft.
V�N,k 5 f"lr:, ire.`7 _____--
Facility/Owner Name Facility ID#(if applicable) it' ft.
s S /...:.,-N ft. ft. 1 to
Physical Address,City,and Zip ft. ft.
21.REMARKS
PerSOn
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
36.y4.341a7 N -7L °pIIcsct w � a--1--- 4577A 3-13_a'
6.Is(are)the well(s) Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or IEK with ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jill 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 I 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: 340 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-36),200'and 202,100') construction to the following:
10.Static water level below top of casing: 36" (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> Yfi (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
(�_ 1 CJS� above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: A.r Y�t'
g rotary,cable,direct push,etc.) construction to the following:
(i.e.auger,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLYWELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test:ay..a'N r2, ,-.s'r1 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: Ifrµ Amount: I`!O a 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