GW1--03907_Well Construction - GW1_20240628

Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
ji('t"L Cook 14.WATER ZONES
Well Contractor Name PROM TO DESCRIPTION
Lis 7-7 A ft ft. 9e2 ft. b G-P/11
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wells)OR LINER(if ap licable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
Copy,Name d ft. G2-7 ft- iv Xi I"- 5D12e21 PVC
/� C� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:Gird-CJ{O 1 33 3 ea ( PROM TO DIAMETER ' THICKNESS MATERIAL -
List all applicable well construction permits(Le.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 OMunicipaVPublic ft, ft. in.
Geothermal(Heating/Cooling Supply) Dirgidential Water Supply(single) ft. ft. fa.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irrigation PROM TO '�MAT�E]RI_AL i EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft-
pZ? tL 1�Note l �� Poi..
Monitoring Recovery [t ft _I cwie I n
injection Welt: ()fare.
1t. R (((TTT���
Aquifer Recharge []Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL ' EMPLACEMENT METHOD
Aquifer Test 0Stormwater 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,hardness soillrock type,grain use etc.)
S'v c2 'I t� ft' ft d Itfi IJtA�' e�1
4.Date Wells)Completed: '1 well ID# ft ff ft. Rad-
5a.Well Location: is ft 400 ft. eTrell R
Mack �� ft. ft : :``,i:.: iEi
1 Oc,at1
Facility/Owner Name Facility ID#(if applicable) ft ft' JUN i A 1 4
3Do Wes� t-oue Dr kn;gl, ,le � s 75� B ft. �itirl 8 2824
Physical Address,City,and Zip ft• ft 1140:416.4 r el 1-,*-411t4;-g lAif
\eJakp 1734/3142,0 21.REMARKS L7J:Co$Gis
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3$-791 ic26a N -7V. Sa'd 391 W 7 7 a s---!G-a y
6.Is(are)the well(s) ermanent or DTemporary Signature of Certified We Contractor Date
By signing this form,I hereby cert(I that the wells)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 knoKw Kell ce nstraretiox information and explain tke,stave 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: 1400 (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: t 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: 6 /' (in.) 24b.For injection Weds: 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.Weil construction method:/ 1 (- 204-a r 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) lint Method of test:CYCX..)II d2zj rylA\ 24c.For Water SUDDIV&Injection Wells: In addition to sending the form to
f� the address(es) above, also submit one copy of this form within 30 days of
�(
13b.Disinfection type: tT i l Amount: I If d Z completion of well construction to the county health department of the county
where constructed.
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016