GW1--03332_Well Construction - GW1_20240603

IPrint Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
(.1
1 ,',. v�-e- -1.--.4./.-4A-Finrd 14.WATER ZONES
Well Contractor Name FROM TO t DESCRIPTION
NC Well Contractor Certification Number 15.OUTER CASING(for muld-cased wells)OR LINER(if a licable)
Water Wizards Inc PROM TO DIAMETER THICKNESS MATERIAL
Company Name
ft. iyv ft. LI in. c, NvC
lb.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,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 0Municipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) E esidential Water Supply(single) ft• ft, in.
Industrial/Commercial DResidential Water Supply(shared) IL GROUT
Irrigation FROM t TO t MATERIAL EMPLACEMENT METHOD&AMOUNTL-'
Non-Water Supply Well: / V ft- 4/0 ft' fia'i 64, P:.l^f / a���s
Monitoring Recovery ft. ft.
injection Well:
ft. ft.
Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL PACK(H applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stotmwater Drainage ft. ft.
Experimental Technology QSubsidence Control ft. ft.
Geothermal(Closed Loop) C3Tracer 20.DRILLING LOG(attach additional sheets If necessary)
Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,aduroele 7P4 grain size,etc.)
ft. ft.
31�/02 i ff. ft.
4.Date Well(s)Completed: Well ID#
5a Well Location: ft ft f
bra 4- hi l le 4- ft. ft.
Facility/Owner Name
IJ,,��``,, -� � Facility ID#(if applicable)
ft. ft. l J k, ._ 2024
caC 1 i Gi °k0 !t` O,(,t-t, ft. ft. Ir,. - .;r--,.sr-1^-il _13:k
Physical Address,City,and Zip ft. ft. Gam'.'„r -
i r, 21. MARKS
/V^ ram--1'V�- .Ry���,-{,, a (''� + �t�
County Parcel Identification No.(PiN) ... r`-S' 'Q- i,/ee I t'.��r. rV r 1 G.c/R-^lT
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/lo`gg is sufficient) �(Yl��/� 2 J 22.Certification:
e3G •0 Iri/36a N — 'V• pk)b. C1 W V/tcl WOOPif 3/OW ic: a
6.Is(are)the well(s) ermanent or Temporary 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: Di4 or 11::}No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out Mrown well construction information amd 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: 2 ..._ (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welts list all depths if different(example-3 'and 2@ 100') construction to the following:
10.Stade water level below top of casing: a ' (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"7" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: G 4 (in.) 24b.For'erection Weds: In addition to sending the form to the address in 24a
vl I above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: b� T`Q�t J 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: C(. %.. 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: I-/1 I II Amount: J U(,t�-5 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