GW1--06090_Well Construction - GW1_20241014

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.W 11 Contractor Information:
i �rlj- di c-d
,iS14:WATER ZONES
-PROM TO DESCRIPTION
We Conttrracct7orrNName r ) tt I ft (A,N
`-'V'V v ft ft. ot �YY�-
NC Well Contractor Certification Number ,15.OUTER CASING(for multi-cased wells)OR LINER(if ap linable)
Water Wizards Inc FROM ft I( DIAMETER in- I THICKNESS vc
Company Name
u1 16.INNER CASING OR TUBING(geothermalclosed-loop)
2.Well Construction Permit#: \INO LI1 --aQ41 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fr. ft in.
3.Well Use(check well use): ft ft in.
.17.SCREEN
Water Supply Well:
FROM TO DIAMETER,. SLOT SIZE THICKNESS MATERIAL
ill •gticultural QMunicipal/Public ft ft. in.,
II Geothermal(Heating/Cooling Supply) glesidential Water Supply(single) ft ft. in.111
DResidential Water Supply(shared) IS GROUT
Irrigation FROM TO MATERIAL s E.ifPLACLMENTM &AMOUNT
Non-Water Supply Well: 0 ft 13/ft W sePot rC•d j / C0 J,,,5
A Monitoring ery ft ft. rW VV (7`/
Injection Well:
It. ft. 1.
I Aquifer Recharge DI Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable) '
NI Aquifer Storage and Recavery EliSalinity Barrier i FROM TO MATERIAL . EMPLACEMENT METHOD
Ili Aquifer Test (jStormwater Drainage ft. ft
II Experimental Technology IDSubsidence Control ft. ft. I'
!'Geothermal(Closed Loop) I°Tracer '20:DRILLING LOG(attach additional sheets if necessary) -_- _ ,
*Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
4.Date WeI1(s)Completed:(/ 44 Weil Dik ft It si t.:.'---- % • I F
ft.
5a.Well Location: ft O C T 1 4 2024
IO011 yvv-6 ft ft ,
Facility/owner Name Facility IDS(if applicable) ft. ft. 1 I Ii J:`,s,;.(;, ,c. ,c', -,V i .:,,
� d l Vint Or 1 ;115& c h ft. ft. D'.=,,. �.
Physical Address,City,and Zip ft' 1
0/1 e' 21.REMARKS p� yQ�
County( U Parcel Identification No.(PIN) X-��'-5 `/ ., ''ef r I-6 "/O
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: C Qr
(if well field,one lat/long is sufficient) 22.Certification:In 1.
�i3O$3tf qqrN 7q°V il6,54-/cj`c2 it w la, ‹i l, g low/ il
6.Is(are)the wells) ermanent or Ii Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby cert('that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 'es or Oi No with 15A NCAC 02C.0100 or 15A NCAC 02C.B200 Well Construction Standards and that a
If this is a repair,fill out k osnr Dell er9:r314WeeNr atcSIVPAStasr eed m$sdv th Ha wof tke 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 pageito provide additional well site details or well
construction,only 1 GW-1 is needed.lnticateTOTALNUMBERofwells eAnStIllCtien.dataik•Yon may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 CO (ft.) .14a. For All Wells: Submit thisi'form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') Construction to the following: E'
10.Static water level below top of casing: g J (ft-) Division of Water Resources,Information Processing Unit, .
Ifwater level is above casing;use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: V "l (in.) 24b For Irrjectisle Wells: Jo e�ddiiioa ice seeming the farm to the address in 24a
I/I,�,( _ ( above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: e/0475 ( construction to the following: 1
(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) i- Method of test p(/L-0i 24c.For Water Supply&Infection Wells: In addition to sending the form to
H fH > the address(es) above, also submit one copy of this form within 30 days of
13h.Disinfection type: Amount: C A.,.A completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016