GW1--03888_Well Construction - GW1_20240628

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
/O/....
1-&--7 1 14.WATER ZONES
Well Contractor Name 1 FROM TO DESCRIPTION
Dft.? << Jy3 ft. /50 ft. /O 6P,✓)
ft.
NC Well Lontractor Certification Number 15.OUTER CASING(for multi-eased wells)OR LINER(if ap ticable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
oft. SOf t( .swuoPi/e_
Company Name 16.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 in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DM cipal/Public ft, ft. in.
°Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. rt. In.
Industrial/Commercial °Residential Water Supply(shared) IS.GROUT
Irrigation FROM r TO I MATERIAL ' EMPLACEM NT METHOD&AMOUNT /
Non-Water Supply Well: D ft- �p f' ft. 3�rr yQr4�/u`i Ofici el /.
Monitoring Recovery 0 EL l0 ft. �// / / /'
Injection Welt: 1Gi/ /Z La� �Ge'` ��'�r4r � , j
fr. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft
Experimental Technology °Subsidence 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(color hardatas soil/rock type,grain size etc.)
4e A 23 5� © �ft. ft- c // .1
4.Date Well(s)Completed:y�I7 ZY Well ID# � `7 q,y / n k
5a.Well Location: )� 24ft.ft2 tsfr IC J( ✓-DDa
CICLs+ILS.�' �Al an.Irpryh f 7- -^ - i
Facility/Owner Name Facility 1D#(if applicable) ft. ft. •`.`e l.. ,1.4 r/I
73 Flu -.0. .e.c ,r. -.56-lorc. lit ft.
e JUN 2 8 2024
Physical Address,City,and Zip ft. ft
#4.: 21.REMARKS 1r4-`-.4:44:C.1 A^'•-Inv; 1 ukk
County Parcel Identification No.(PIN) DV.C. *(its
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(if well field,one lat/long is sufficient) 22.Certif do :
/13b°3/ '3 2.. 5 nok,' J no)3-3, 47c fp2
6.Is(are)the well(s) rmanent or Temporary i� of enified W o ,.trot Date
By signing this form,I hereby certffi that the well(s)was(were)constructed in accordance
7.1s this a repair to an existing well: OYes or Do with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well cm:smartion 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 DW-I is needed. Indicate TOT AL NUMBER of wells constrtution details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 220 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 7 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: " (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
I - above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: �.1'l 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: �7 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) l D Method of test: � i-t/�j Ue. ..... 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: H 7t,// Amount: (Q aOlC(.5 completion of well construction to the county health department of the county
Iwhere constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016