GW1--04979_Well Construction - GW1_20240828

IPrint Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
U/K i I [(Is N 1 14.WATER ZONES
Well ComteCtor Name I FROM TO I DESCRIPTION
t) fit. C ( ft.
'jy73 A ft. fr.
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 ID ft. 54 ft. /S/„ lo. I ;7.4 Pvc-
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. to
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft- p, In.
Geotherrrnal(Heating/Cooling Supply) Residential Water Supply(single)
f4 fit. In.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO ' MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: V ft 54 rL t.I q 7 Po el-14 0e Fo t.trtte Z$b'
Monitoring DRecovery ft. ft.
Injection Well: fL R
Aquifer Recharge QGroundwater Remediation I I .SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery QSalinity Barrier FROM TO 1 MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft•
Experimental Technology DSubsidence Control ft• ft.
I Geothermal(Closed Loop) QTracer 20.DRILLING LOG(attack additional sheets If necessary)
Geothermal(Heating/Cooling Return) QOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type grain size,etc.)
ft. ft.
4.Date Well(s)Completed:7-2 3'202'I Well ID# ft ft.
ft. ft. �' / :--,
5a.Well Location:
ADNli KRI ?gape0ics AUG 2 8 20?4
Facility/Owner Name Facility lD#(if applicable) H. fit
ft ft 1., '..i?.ii
.Ls -ILs:1C a1(.kS (Z.� Di..;.. ,
Physical Address,City,and Zip ft" fr
Pe K S J 4 1)5 /4/6 21.REMARKS
County Parcel Identification No.(PIN) .4 t1 Sih 1I I-t not- +i5 stop r e(.-k;ilS C 14$j rt,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: d
(if well field,one lat/long is sufficient) 22.Certification:
310.1-102243 N - 79,o)-104,70 W U pp 7-aq-20.Y
6.Is(are)the well(s) Permanent or Temporary SignaturlofCertified Well Contractor Date
By signing this form,1 hereby certifi that the well(s)was(were)constructed in accordance
7.Ia this a repair to an existing well: )Yes or ONo with I SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
If this Is a repair,fill out knohw Hell construction 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 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: 10 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if Afferent(example-3@200"and 2 tt/00') construction to the following:
10.Static water level below top of casing: 9.'5 (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: V•'II (in.) 24b. For!election 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.Well construction method: 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) 10 Method of test: a u t1 I) 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
1 13b.Disinfection type: H TO Amount: p i or 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