GW1--05709_Well Construction - GW1_20240920

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well Contractor Information:
L c.; 14.WATER ZONES I
C•• C FROM TO DESCRIPTION
Well Contractor Name
ft. S'c) ft !,Pilo
c-!s�`7 ALIS 55"ft. aC0 ft. 9 !G.P►„ i •
NC Well Contractor Certification Num tr. 1S,OUTER CASING(for multi-cased welts)OR LINER((f ap Rabb)
Water Wizards Inc FROM TO DIAMETER THICKNESS
o ft. ra9 ' , 6,J. in.: sDe.aI C
Company Name 16.INNER CASING OR TUBING(geotttcrdtal closed-loop) :YID'
2.Well Construction Permit t: FROM TO - DIAMETER a THICKNESS MATERIAL
List all applicable%ell coast:valan permits(i.e.UtC,County,Slate,Variance,etc) 0 ft' 76 f y in'' Sa% 40 PVC
ft. . ft. in.
3.Well Use(check well use):
17'SCREEti
Water Supply Well: _ 1
tira n nc t ATERIAL
Agricultural Municipal/Public ft. ft. - in.
Geothermal(Heating/Cooling Supply) sidentiat Water Supply(single) ft, it In.
IndustriaUCommerciat DResidential'Yater Supply(shared) is. T'GROU r
Irrigation FROM TO dtATERtAt. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 fe• R. 3 ikke Pex,,flsc3 4- (-rx
Monitoring alecovery ft. ft. I. trl e ickc.e 75b I bs .
injectionWell: • 0 ft, 7w ft. meal, j. 1f'Oe�ftGd Os 1 bS
Aquifefer Recharge QGrotmdwatee Remediatian 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0SalinityBarrier FROM TO MATERIAL. EMPIACEMENTMETIIOD
Aquifer Test °Stormwates Drainage ft. ft.
I
Experimental Technology OSubsidence Control R. R. ,
Geothermal(Closed Loop) OTracec 243.13RILUNG LOG(Mtneh additional sweets if memory)
FROM TO DESCRIPTION(color,(rattiness.solUrotk type.grain size,etc.)
at3eotheumal(lleatingl cc. ft Cooling Return) Other(explain under#21 Remarks)
LL'' 0 0� O(rer�r��
4.Date Well(s)Completed:Z-( -12 Ll 'Well ID# a ft 1$ ft. Qed C.)a y
5a.well.Location: - 1 S n 93 ft 50-nd
‘ -fie S Po r teS 1 073 300 i' &1b( e,och_
Facility/Owner Name Facility Mt((if appticabta) ft. ,I .• -, +r, r,--- )
3s a I sI- Qd Crkar-, Sb e2' ft. ft. .. •.
Sam�.r":...: :,S:iAO
Physical Address,City,and Zip f ft. ft. S E P 0 2121
�, 2L REMARKS
County Paced tdentifldatioallo.(PIN) 1r tc:r.rnr.i•'.c fl ?rr r.;,d's`:t.%,.2 t t rail
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r
(if well field,one tat/long is sufficient) 22.Certification: `
36.iTs7G3a? N --7v. vit/179 w .- �L.i467, A "]-!02-e2t/
6.Is(are)the well(s)erermanent or Temporary Signature of Certified Well Contractor Dale
� By signing this form,I hereby certh'that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: !1V es or 11"; "Kith ISA NCAC 02C.QIQ0 or ISA NCAC 02C.0200 Well Constriction Standards and that a
If this is a repair:Jill out knoan nellcanrwstcttay Warr-nation and es$/a the nmarvofthe cops'afthts record has beenj'rocided tithe sell avatar.
repair under 021 remarks section or on the hark of thisform. 23.Site diagram or additional well details:
S.For Ceoprobe/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
constmctian,only 1 GW.t Is deeded.LtoicateToTALNUMB➢R of wells eOust u°6' its'Y y also attackashlitionat pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 300 (ft) 24a. For MI Wells: Submit this form within 30 days of completion of welt
For multiple wells list all depths if d jferertt(example-3 00'and 2 tr.100) construction to the following: 1, ,
r
10.Static water level below top of casing: O (ft.) Division of Water Reisources,Information Processing Unit,
{(Twofer level is above casing.use"`+" / 1617 Mail Service Center,Raleigh,NC 27699-1617
li.Borehole diameter: O r� (in.) 24b.For injection Wells: In addttioa to sending the form to the address in 24a
�� �^/ t above,also submit one copy of this form within 30 days of completion of well
P)12.Well construction method: r 1`O construction to the following:
(i.e.auger,rotary,cable,direct posit,etc.) •
Division of Water Resources,;Underground Injection Control Program,
'FOR WATER SUPPLY WELLS ONLY: 1636 Map Service Center,Rateigh,NC27699-1636
13a.Yield(gpm) 1.3 Method of testa ID L.-Net r�Ioil\ 24c.For Water Sunnly&Iniection Wens: In addition to sending the form to
+y
� the address(es) above, also subunit one copy of this form within 30 days of
' 13b.Disinfection type: 14/.1/ hum pact. {4 d Z. 1 completioa 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