GW1--03886_Well Construction - GW1_20240628

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: r--
1.Well Contractor Information:
6 4-F✓ k Sow\f--Q--e 14.WATER ZONES
eWell Contractor Name t FR M TO ) DESCRIPTION
`"G e- 4; -I 6 1 ): 66l f / 2/11
ft. .iL
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(If ap licable)
Water Wizards Inc FROM TO DIAMETER THICKNESS
MATERIAL
Company Name U ft.
(TO 44 tin- S O i " '�r��",',� fr
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.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft is
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM ' TO ' MATERIAL ' EMPLACEMENTLE METHOD&AMOUNT
Non-Water Supply Well: U ft.
44'i ft. v69-0-4- f? -"F/ O`4
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer i 20.DRILLING LOG(attack additional sheets if necessary)
Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DF.SCRIPTION,eIor,hardness,sail/rock type,grain tire,etc.)
[� /� ft. ft. I .. : -•. .'. t a
4.Date Well(s)Completed: %/to /a/n 9Well ID#r'I6Z-45 it ft. ��.
Sa.Well Location: ft ft JUtN 8 Z024
/ L'/ cam P t/v Ka-i♦��j44 ft. tt
�J' If..i.:r.:.aci ' ^^ar.4. ; JrR
Facility/Owner Name Facility Mitt(if applicable) ft' ft' of Cs• $t.�
1%�-0r•�- T v2--. ft. ft.
Physical Address,City,and Zip ft. ft.
t .i--5apl 11.REMARKS d /�,
unty Parcel Identification No.(PIN) 'Le 1- I Q-427-6-15
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ( " :)
(if well field,one lat/�lonngg is sufficient)nt)) 22.Certification:
,a v6`72su63 N ✓7<J. q q.3- W
'1.----- .1-\ekri, 67? l h2q
6.Is(are)the well(s) ermanent or Temporary Si lure of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: tQxes or ❑No with 1 SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well emvstrartiow information and explain the nature oftke 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-I 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: 6t,U (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: O"'' (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: (9 WI (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
I c� _.i] �i above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: IL -�O`4�!Y construction to the following:
(i.c.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) O Method of test: G u�/Ai 24c. For Water Supply&Injection Wells: In addition to sending the form to
1-14 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-20t6