GW1--04975_Well Construction - GW1_20240828

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WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1. II Contrac r Information:� ti
rail i/r) 14 t ACt/71 (L1.) 14.WATER ZONES
Well Na� //Qa� 2,,(ft. r7;70,-
�kY 2 � �it/G7� � d/JP
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wells)OR LINER(if aT7v
cable)
Water Wizards inc FROM TO D ETER THICKNESSMA Company Name m . D
16.INNER CASING OR TUBIN .eotbermal closed-loop)
2.Well Construction Permit#: t� D - TER TH KNESS MA
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) de ft. 0 ft- R, In. C-0/ I /C
3.Well Use(check well use): ft ft. in. 0 v
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Agricultural D icipal/Public ft, ft, in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft.
ft. In
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irrigation FRO TO _`TE L CEMENT M IODBA QON(T
Non-Water Supply Well: rt.
SZ ft L'^ [ % G/v!!L/�J
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery
Aquifer Test
Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
0Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. ft
I Geothermal(Closed Loop) °Trace[ 20.DRILLING LOG attach additional sheets if seems:Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness vaUrock type grain siz etc.)ft- ft. _
Q t
4.Date Wel!(s)Completed:/ V Well ID# ft ft. p ►'
_
Well Loatla ft- ft- t� ~d.`
14/ K-A/re e I ft. ft. -- 2 s 2024
Facility/Owner Na Facility[D#(if applicable) ft' ft' pre: -_,-r,� t
c0' T fey s / L h ft. Of. -.07•
Ph 'cal Address,City,and Zip ft. ft.
-pOf�n 3g' 1 Lk .RE fps J �J��
County Parcel Identification No.(PIN) ill /,(ao�/ G/c/if / ../ /
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: / /- f4 e /,etc.., 11- /' 14 /1-7
(if well field,one lat/long is sufficient) 22.Ce atimn• Z- e'
N W 7--- / g-2
6.Is(are)the well(s) Permanent or °Te rary ignamre o e .._•_
rtifibd We o Date
By signing this form,I hereby cerlt&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: es or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construe/km information and explain the nature alike 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. Ind'icate'SOTAL NUMBER of wells construction details. You may also attach additional pages if ttexessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if d(erent(example-3 0'and 2@100') construction to the following:
10.Static water level below top of casing: (ft-) Division of Water Resources,Information Processing Unit,
If wetter level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in. 24b.For MOO-km 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.Weil construction method: �( Cil/y 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: p 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: / 24c.For Water Supply&lniection Wells: In addition to sending the form to
,, C the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:�/V�i/') Amount: fit 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