GW1--04980_Well Construction - GW1_20240828

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
VI a i t (A)I IS d 14 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
1.1L17 3 A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap linable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 30 ft 10 in.
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.) 0 ft. /�5" ft. L/ in. S Q r, ate V. pik
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft In.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared)
IS.GROUT
Irrigation FROM TO t MATERIAL-7-7 EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft.
Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge 0Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery C3Salinity Barrier FROM l'O MATERIAL EMPLACEMENT METHOD
Aquifer Test fStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) C3Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM 1 TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) t
,�/ Other(explain under#21 Remarks) ft. f
4.Date Wells)Completed:11-1 "aC ZL Well ID11 ft' ft' ! '--
5a.Well Location: ft
Cur,+gal ARI( Cusfod't,v,
stun^ ft. ft. AUG 2 S ZUZ4
Facility/Owner Name 511",14/ Facility ID#(if applicable) ft'
36 Me5AN KNv RoxboiZo NC- a-1S7y ft. ft. [�;.,:..
Physical Address,City,and Zip ft. ft
i'e O N `Ri 5Q 21.REMARKS
County ParcelldentificationNo.(PIN) .0-1 IN51'N)) bnek Ia 15 lte•je r1Ncey w.4fiiC
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C `f atio •
:36.3S-3Z 53 N '7 8.92 b( W �/ /�, �" R:2 20-2Y
6.Is(are)the well(s)12Permanent or OTemporary Signature Certified Well Contractor Date
By signing this form,I hereby certh•that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or [)No with I SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out kno,n Nell constewetisw ixkirmatiov and expaarx 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 sitc 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: 300 (1t) 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@l00') construction to the following:
10.Static water level below top of casing: 1T0 (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: G (in.) 24b. For Injection 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) 3 Method of test: 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: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016