GW1--03882_Well Construction - GW1_20240628

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contrac or Information:
Ill t
ria4 /N / G 1 w('h 14.WATER ZONES t
FROM TO DESCRIPT out
Well Contractor Name �ji ft. f s ft, �N / Q p 1 J C �C1 )4 j
2 7 qG ,� ` iz U ) 1 , �f- 1L h
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap ble)
Water Wizards Inc FROM TO D1A�TER ,��KNESS�i MAT��
aft O ft. in. f C j (q4
Company Name 17 t
\fi�(�,t r�- C)( ^3 MANNER CASINO OR TUBING(geothermal closed-oop)
2.Well Construction Permit#: iX", (J �( FROM/y TO D rt R THIC E A RIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) V ft• 75 it in. sr(Va MPVC
ft3.Well Use(check well use): In. ���7777
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
AgriculturalCI y6icipal/Public ft. ft. M.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. rt. in. i
Industrial/Commercial DResidential Water Supply(shared) i
IS.GROUT
Irrigation ' FROM TO TE EMPLACEMENT METHOD&AMOOyNT
Non-Water Supply Well: C IL 75 ft coy.„/ P.9 4/ T a /rJr
Monitoring DRecovery ft ft.
Injection Well: i
ft. ft.
Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage ft. ft
ExperimentalTechnology QSubsidence Control ft. ft.
Geothermal(Closed Loop) QTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO DESCRIPTION eabr 4rdncns unfrock type Grain Yu etc.)
4.Date Well(s)Completed: ,Z Well ID# ft. ft.
1
Sa WeQLoca�'°u: ft ft JUN 2 8 2024
4t.
n�PIG1 S+S fMarr f' ' lref£:r.r,t;r, ',tea• tic
Facility/Ow�,r Name Facility[DP(if applicable) ft. ft. Dti(.J ICI;
e
�G// 7/�f' ft ft
Physical Address,City,and Zip / ft ft.
Countveil �/%{ , 21.RE�M"FKS ` f
y l C Parcel Identification No.(PIN) 1 r/r,// ,��e4 /^ / .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: T, C /�e -', - 4-3( '/c ��,,
(if well field,one lat/long is sufficient) 22.C 'flea n:
N W .� ,s z;-22,
6.Is(are)the well(s) ermanent or QTe rary Signature ot<C'ertifi el Date
By signing this form,I hereby cent that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ¢a or QNo with I SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fell out known aril cm:soa-non 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: r 93' (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'a 2@/00') construction to the following:
10.Static water level below top of casing: Z (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: t t9 in.) 24b.For laiection 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: GI/ 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: /J 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) £.' Method of test: /3../Y'// 24c.For Water Supply&Iniection 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: ar/./19 Amount: (/�ey.( 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