GW1--06114_Well Construction - GW1_20241014

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1,Well ContractorInformation: /1 j
14.6 WATER ZONES I 1
Well Contractor Name FROM TO DESCRIPTION I
(46(‘-l-6 PO ft. " 46 ft. t 03P 44
ft
NC Well Contractor Certification Number
15.OUTER CASING-(for multi-cased wells)OR LINER(if ap licable)
Water Wizards Inc FROM TO DIAMETER; THICKNESS MATERIAL
Company Name U ft er0 ft. 11 in. S0 it 2Cr PVC
16.INNER CASING OR TUBING(geothermal closed-loop) "
2.Well Construction Permit#: 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: FR MCEN TO DIAMETER 'SLOT SIZE THICKNESS MATERIAL
a Agricultural I011/44 ,'cipal/Public It ft in. I
$Geothermal(Heating/Cooling Supply) -a.Residential Water Supply(single) ft ft in.
a'Industrial/Commercial OResidential Water Supply(shared) •
18.GROUT '
I Irrigation FROM 1 TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Ur ft cry ft. Qb�/0250
7 1(JS
U'Monitoring 'ecovery f. ft. I
Injection Well: •
ft ft •
ii Aquifer Recharge QGroundwater Remediation '
19.SAND/GRAVEL PACK(if applicable)
jji!Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL' EMPLACEMENT METHOD
aIAquifer Test DStormwater Drainage ft' ft i•
(I Experimental Technology ' 0Subsidence Control ft. ft.
111 Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sbeets if necessary) ' . ' -
111
Geothermal(Heating/Cooling Return) Other(explain wider#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type grain sire etc.)
y�/_s- r �7 ft. ft.
4.Date Wells)Completed: 7�6I�c2i® r7 Well ID# (G �5 7, ft ft (; . - .-, T_
5a.Well Location: ft. ft I ;�„_(,,.,, "'j a 'r.-., " '`.
ZS et"liPer 1-4 -I[e.er— ft ft T ,._ Li
Facility/Owner Name
� �,/gyp L Facility ID#(if applicable) ft. ft 2024
t, � 1 e ✓✓V ( ft. ft. • (ii':,:. r.t �'nrY _
Physicalft. ft. i+:a t,�•'=tom. )t
Address,City,and Zip
er no 21.REMARKS I
11V 7 _ ' 1 'ter ��''c
County PareelldentificationNo.(PIN) t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
S(0, -6(C1 "79,3 N ` '7 Y.I(c(G 747 W ac.-keJ -7/61/.9.61
6.Is(are)the well(s)1D.P.errnanent or j (Temporary Signature of Certified Well Contractor Date
� By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
�{
7.Is this a repair to an existing well: L.Y�" Dot E)No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If Ibis is a repair,fill out known orll constrwctiaw information and explain the nature of the copy of this record has been provided to theiwell 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' I
construction,only 1 GW-1 is needed.Indicate TOTAL13l)MBER of wells 6onstruction derails.You rna'also attach additional pages if necessary.
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drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I LI v i.
(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(Qa 200'and 2@100) constmction to the following:
tn� , 1'
10.Static water level below top of casing: O, - (ft.) Division of Water Resources,'Information Processing Unit,
• Ijwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617/
11.Borehole diameter: l 9 (in) 24b For Injection Wells: In addit•p 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: 1i construction to the following:
(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) /iii Method of test: 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: i'tr' Amount. C)"C.P`Q completion 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 i Revised 2-22-2016