GW1--06089_Well Construction - GW1_20241014

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ,
IS Its- 1
14.WATER ZONES I 1
Well Contractor Name VROM TO DESCRIPTION
[ /� ` A Lid at. ft. 3 w►'
-t''y 7I ` ft. It.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Wizards Inc FROM TO DIAMETER, THICKNESS MATERIIAL-
Company Name U it �O ft N 11- W O pv(/
1 n1 C 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: V, 4'" 0153 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN -
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
III Agricultural QMunicipal/Public ft. ft. in.,
111 Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft ft in.
"Industrial/Commercial DResidential Water Supply(shared) 18.GROUT , ._ . - ---
( Irrigation ft.OM ' TO O ij ft MATERIAL 6-1- ' EIfPLA�i� / �JD&jf/005-
Non-Water Supply Well: 0 o f�kk��//J�`' !/Y7 0CJ4✓�
all Monitoring ecovery ft. It.
Injection Well:
ft. ft.
is Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
III Aquifer Storage and Recovery ' C)SalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
®Aquifer Test I)Stormwater Drainage ft. ft.
®Experimental Technology ()Subsidence Control ft. ft.
•'Geothermal(Closed Loop) (jTracer 20.DRILLING LOG(attach additional sheets if necessary)
TO DESCRIPTION(color,hardness
II Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROMsoturock type,gram size,etc.)
ft. ft.
4.Date Well s Com leted: ///q/ ft. ft. ' ', ; -_
() P ![(//� Well ID# � F.�.. Y �!i
5a.Well Location: ft. ft "° ?� •..,f
5CO-IA Pt�st 114 ft. ft. 0 C T 1 4 2024
Facility/Owner Name Facility I1311(if applicable) ft. ft 1
6'30 ot/t t v .e .,(J14, 16.4./ ft. ft II.w.....a..:C-•..i, , -" �h•`Y...
Physical Address,City,and ft. ft.
C D. 21.REMARKS
Countyv Parcel Identification No.(PIN) ( t"'iv r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �5 42.1 i
(if welll field,one^lat/long is�suffiiciient) -��j n e� 22.Certification:
G, /V��JcC N L <7•t or•d°Od"1 W '/ �� _f��
f4�' c��9�+v uU 7/lam/o -ii
6.Is(are)the well(s) ermanent or L.-)Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: i es or DNo with 15,4 NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well cawstrwc?iow information and explain the nature of the copy of this record has been provided to Bie 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'NUldBBR of wells construction details.. You may also'attach.additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS 1
9.Total well depth below land surface: ►,w% tic C) (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(1d(Qerent(example-3@2 t t'and 2@100) construction to the following:
r°
10.Static water level below top of casing: �h (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,usse�"`" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: V (IQ 24b.For Injection Wells: in addition to sending the form to the address in 24a
y -,]___� above,also submit one copy of this form within 30 days of completion of well
� /12.Well construction method: f�,0 Or construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) a Method of tests p/1ri''M�Q 24c.For Water Supply&Injection Wells: In addition to sending the form to
(,++ r , J the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 11 1-i1 Amount: /"9 adt-e-/S completion of well construction to the county health department of the county
where constructed. I '
11
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016