GW1--05684_Well Construction - GW1_20240920

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
11
ell Contrac r Information:pO-. L � (t( I `ai < 1
��� t�Yl 14.WATER ZONES Q !
FROM T OFSC ON
Well Contractor Name i?5 ft. �. ter_• C /Of 007
2. 7 q(, % ft. ft G
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Wizards Inc FROM TO TITER THICKNESS MAf
Co Name 0 ft. 7 q ft , in. t y 77 6u/IX
Company 1nI `^ 16.INNER CASING OR TUBING(geothermal closed-loop)
2. 1
2.Well Construction Permit#: Y V a0r O\p`� FROM 10 DI ETER TmIge E5sS h}QTERIAI,
r `J�/ rJ'"J
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ® ft. 00 ft. rn. s'c. G
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER. SLOT SIZE THICKNESS MATERIAL
ll Agricultural DM ipal/Public ft. ft. In.
1111 Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
*Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
I !Irrigation OM TO ' A A K LACEMENTME' I��MIA.,
Non-Water Supply Well: Mgt ft �,l ft/ / rein/
T.
,f`J 2id!^'
®:Monitoring IlRecovery ft. off {t
Injection Well: ft. ft.
*Aquifer Recharge ID Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
®!Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
*Aquifer Test (jStormwater Drainage ft. ft.
1 Experimental Technology IjSubsidenceControl ft. ft.
I]!Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
II Geothermal(Heating/Cooling Return) °!Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
(� l/ ft. ft.
4.Date Well(s)Completed: J 1b l'Z ell ID# ft ftft i7.. ,, e a .
5a.Well L tion: i e „7
ft ft.
J a(r;f ft ft. SEP 2 1.
Facilin /OwnnneerName Pao
'itID �a bCfOyP4 b pplle)
�/- I 6l ft. ft 1i,::i:'r:w.i:f,..; nrr.f �.
ft. ft.Physical Address,City,and ZipC,`'•a';�+v
Clficf 019^e 21 A
County Parcel Identification No.(PIN) r4 a �..ii l 1/s►.r!/ dttih
l'"5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ' `®a A0 leo Cy✓f Ca‹,
(if well field,one latllong is sufficient) 22. lion:
N W I .,/6,.cib/
6.Is(are)the well(s) ,Permanent or it •emporary - Signature of Certified We ontractor Date (( `"
By signing this form,1 hereby certj tlmtjthe well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: i©Yes or Olio with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
/fthfs is a repair,fill out known null conrtruction 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:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL73UMBERofwells construction details.Von may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: t) (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ft-different erent(example-3@.20 and 2@I00) construction to the following: i
10.Static water level below top o6f casing: (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
J�a f above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: l iJ / construction to the following: i
(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) Method of test: �i:il/1'� 24c.For Water Supply&Injection(Wells: In addition to sending the form to
l C f the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: �i��1 P Amount &tpcompletion 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