GW1--03846_Well Construction - GW1_20240628

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
6 mc. Czok. 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
yg 7 7 A I so 115 GPM
NC Well Contractor Certification Number 1�s ft 1 -
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Wizards Inc FROM ' TO ' DIAMETER THICKNESS MATERIAL
o ft. irtl 11 y in. %PRa) Pvc
Company
Name
2 lb.INNER CASING OR TUBING(geothermal closed-loop) • e'
2.Well Construction Permit#:P- & q 31( FROM TO DIAMETER THICKNESS _MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) D ft. I os- I ft• t- in- s L L'1 o p�
3.Well Use(check well use): ft.ft. �1 1
Water Supply Well: 17.SCREEN
FROM TO
ft
ft. ft.
SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft In.
in.
(Heating/Cooling Supply) Eresidential Water Supply(single)
Industrial/Co
mmercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO ' MA TER/AL s EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. D O ft3fre llokS POt,dtel 4 ayetell 4e In r hu,,
[Monitoring DRecovery O ft. 1n5 ft. _.�_1 p Au IL� ��••tioof
Injection Well: , N+ Imo+ clad v
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 9Stormwater Drainage ft- ft
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additlooal sheets if accessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
b ft. A ft. o ter•kc.m4
4.Date Well(s)Completed:(C'17'aq Well ID# 2 N- c) ft- n - •
, 4
Sa.Well Location: Go �vft. RG� ► • 7 _
S►NCira. &A;ICI 9 fL d 140 ft. 6-cy ' •eit.
Facility/Owner Name Facility 1D#(if applicable) ft. ft' ,
3%y " L Iy /1 I fL ft. . lr.D
t7(O� l� ""JJ 1�1 OX C� ?S�PS ^`, `•L.�; V V
Physical Address,city,and Zip ft. ft'
&MAU1Ik ► 1270°34,2773 21.REMARKS JUN ?, 8 2024
County Parcel Identification No.(PIN) Ualt
lI e(fl:RSllri:.c.l i''c^ltiA4:^9
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: D'j'("v3 ?i
(if
�'well field,one lalllong is sufficient) �7�j 22.Certification: /� t,
34•y30014 N '• ID.61.0,11 W 'i577 1"1 t,-17`07'1
6.Is(are)the well(s)Ofermanent or DTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certifythat the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or Er° with ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out kaonw well eoscs eases Wm—motion 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 derails. Yen may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ko (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths f different(example-3@200'and 2@ l0U) construction to the following:
10.Static water level below top of casing: av (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: ( P 'I (in.) 24b.For Injectioe Wells: In addition to sending the form to the address in 24a
/^�• n above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: air r I�ptO 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) I p Method of test:pldU/1 I A,'/) 24c.For Water Supply&Injection Wells: hi addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: FITiN Amount: I U Oa completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016