GW1--03885_Well Construction - GW1_20240628

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
t.r. L Cook 14.WATER ZONES
Well Contractor Name FROM TO t DESCRIPTION
4 7-7to ft• irs,.l a G PrA
NC Well Contractor Certification Number (aD-ft I v I &PM
15.OUTER CASING(for multi-cased wells)OR LINER(if ap cable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL,
� y Name
ft. (.,3 R. Yq in. st Q�7t' Pvc
���.�/�QI-Q /�� 2 lb.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: t�W P'(/Vv IILJ / p(LJ�J FROM TO DIAMETER THICKNESS - MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. is
3.Well Use(check well use): ft ft is
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural OM icipal/Public ft. ft. la.
Geothermal(Heating/Cooling Supply) M,Aesidential Water Supply(single) ft. fL ' is
Industrial/Commercial OResidential Water Supply(shared) IL GROUT
Irrigation FROM i TO ' MATERIAL ' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: n ft- bi 3 ft. 3/8r hale ffen 75"O t laS ?Ot,C a
Monitoring Recovery ft. ��/I
Injection Well: Nydr-aAe 1 n 'Ida CO' 1
ft. ft.
Aquifer Recharge DGmundwater Remediation 19.SAND/GRAVEL PACK(it applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD ,
Aquifer Test OStormwater Drainage ft• ft
Experimental Technology OSubsidence Control ft. ft
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(cube,hardness soil/rock type grain sir,etc.)
D ft- ' aVe--ck trimien
4.Date Well(s)Completed:N 23-a y Well ID#A v G9 -9 9 ,1 ft' �33rp,' ft' �.1 IL
5a.Well Location: ft- ft. & 4�ii ""' -
e {� Its Sc A)�Ac-tJ n ` L.`' VI -L/
Facility/Owner Name Facility ID#(if applicable) ft. ft
133( 14la I- Vitt., Ci- VA Qo bo ro a 1 s-8 ft. ft. Jti`N 9 8 2024
Physical Address,City,and Zip ft' tL (rrico:^,( r rl 1-r.r,SAR;•!i 1
21.REMARKS Chlt'Caf
Person
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
36•S-A7?N4 N - 71. V , w /i1- `4'77 a 4-a3- it
6.Is(are)the well(s) ermanent or 13Temporary 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 No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well eautrartlem infavntatiar and explain tke 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: 3av (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@100) construction to the following:
10.Static water level below top of casing: e2 S (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: tof'!S fin.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
A/� above,also submit one copy of this form within 30 days of completion of well
RD 12.Well construction method: :ri 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) 3 Method of test: +)r t t Ply)>`,� ) 24c.For Water Supply&Injection Wells: In addition to sending the form to
''99 the address(es) above, also submit one copy of this form within 30 days of
R 13b.Disinfection type: T II Amount: IS O Z 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 2-22-20(6