GW1--06056_Well Construction - GW1_20241011

- Print!ormI1 WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1. Contractor Information:
6 trJY16ilrC e,
� 4 14.WATER ZONES ' '
Well Contractor Name FROM TO DESCRIPTION
1t(7-L 702 ft 'in ft.ft CrWfitt
NC Well Contractor Certification Number .15.OUTER CASING(for multi-cased wells)OR LINER(if ap Stable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name
UIt. &VR. q ,ia 40 PVG • .
��^ `_' ��' 16.1NNER CASING ORTUNN (geothermal closed-loop)
2.Well Construction Permit#: 2.w _d FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft ft. , in.
3.Well Use(check well use): k in.
17.Water Supply Well: FROM SCREEN OM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OM t'cipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Via•'esidential Water Supply(single) ft. ft. tn.
Industrial/Commercial D1 Residential Water Supply(shared) 10.GROUT -
Irrigation FRO TO`� ' MATERIAL - EMPLACEMENT It D&AMOUNT
Non-Water Supply Well: ( f. (9 Int. p cd-
Monitoring EIRecovery ft. ft.
Injection Well:
t� ft ft. ,
Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(it applicable)
Aquifer Storage and Recovery QSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IJStormwater Drainage ft ft
Experimental Technology OSubsidence Control ft. ft. '
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,sail/roek type,grain size,etc.)
Geothermal(Heating/Cooling Return) nI Other(explain under#21 Remarks) ft ft.
7��a1 i f. ft
4.Date Wel(s)Completed: �t'7ycJ/O�"I 7Ve11IDt� t.,
ft. ft. �..." .� :. „a -i'' r*i-'--5a.We Location: . '"�- S,.a is •, v t,w;; '
�l �ry ��,I( _ ft. ft. OCT1.:; r V Tt1
4-0 I
Fac9 sty/Owner Name ( ��//ff Facility TM(if applicable) ft. ft. 1 _ 1024
17_ "T�r I-/e, 1g..�/1,itA 1�c3_ 1 ft , rut Ire-,i--:i.:�:, ?
Physic I Address,City,and Zip ft. ft. G�`'r'c5.c'L' "' �' Sii
c�.s
J1 .(�� 21.REMARKSC J 0.
County 1�vy� Parcel Identification No.(PIN) �J �tt %j�/ -, I s "�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �-e
in - ! •
(if well field,one tat/long is sufficient) 22.Ce 'freation:
36°l 'c-rc/daft' -2 a-1 I e46. 3 '' ;,, U / -C1
6.Is(are)the well(s) ; ermanent or Temporary Signature of Certified Well Can ctor Date
By signing this form,I hereby cert fy that the well(s)was(were)constricted in accordance
7.Is this a repair to an existing well: W or O§No with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out brown Hell construction iwformatioe 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/arm. I
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 pages 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 attack addition(pages if necessary.
drilled:
;_�!a SUBMITTAL INSTRUCTIONS I
r: q q
9.Total well depth below land surface: �'i (ft) 24a.For All Wells: Submit this I form within 30 days of completion of well
For multiple wells list all depths!I-different(example-3• 00'and 2®100'),_ construction to the following: ,
.rs
10.Static water level below top of 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: v `1 (in.) 24b.For Injection Wens: 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: r. T1�1` construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) 1 .
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY)WELLS ONLY: " 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 Method of test: e IVY 24c.For Water Supply&Iniection 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: 144
(e Amount: 1.Y O 'z.-. completion of well construction to the county health department of the county
where constructed.
l'
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource' Revised 2-22-2016