GW1--06115_Well Construction - GW1_20241014

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: \I
`14.WATER ZONES I 1
Well Contractor Name FROM TO DESCRIPTION
u S —if C, ft. ft. la KI kPCQA NI
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap &able)
Water Wizards inc FROM TO DIAMETER THICKNESS MATERIAL
ft. ft- ; in.
Company Name
u 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: Nor P.Ems{ .rgr','' FROM TO DIAMETER THICKNESS MATERIAL .
List all applicable well construction permits(i.e.UIC,County,State,Variance, ft. ft. ' is
3.Well Use(check well use): fL ft. in
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
®Agricultural 9Municipal/Public © ft, TA ft- is
lig Geothermal(Heating/Cooling Supply) (esidential Water Supply(single) it iL in.
11 Industrial/Commercial DResidential Water Supply(shared) 10.GROUT `
I._ Irrigation FROM TO ' MATERIAL -EMPLACE MENTMETHOD&AMOUNT
Non-Water Supply Well: ft ft ,
MI Monitoring jRecovery ft. ft.
Injection Well:
ft. ft
I Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
ill Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL ' EMPLACEMENT METHOD
((IAquifer Test {jStormwater Drainage ft. ft. I.
is Experimental Technology DSubsidence Control ft ft.
a,Geothermal(Closed Loop) [Tracer 20.DRILLING LOG(attach additionatsheets if necessary). i
FROM ' TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
)r Geothermal(Heating/Cooling Return) ID Other(explain under#21 Remarks) ft IL
4.Date Well(s)Completed: /0-3-ay Well no �17‘ I ft , ft. ‘hT.i'l
,fift. ft ?TM,4.1
5a.WellLocation:
i3u2Tj REEL ILI GR it t` OC 1 4 2024
Facility/Owner Name Facility LOP(if applicable) ft. ft J r` `.;, -? ^^^ '
ft. ft. c ._ a
3 ►1 C iT ; E RD, i G�abtw G:=r
Physical Address,City,and Zip
�N` ft. ft. ;.
PGRsaI\I �211.REMAR/KtS,.,�/ /�/�1�'t ,Ir;- �S
County Parcel IdentificationNo.(PIN) ✓sARV/V V V/O // *ni l e R M A E TO
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: SCREW/ ijg £Z0 NOT Cd NSr/Z UCr ,
(if well field,one lat/long is sufficient) 22.Certification: 7"ti-D S ( $ti E LL.
3(2, a3ei ?7 3 N --7?, c13 'c?ba w r
�Ukok &A Sao V 145-3 -ay
6.Is(are)the well(s) Permanent or ]Temporary Signature of Certified ell 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: Q1 Yes or DI No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known null emss-tove:ie,l ,... :....em(ezpdzamthenattnofdx copy of this record has ovidedxo well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For GeoprobelDPT 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 TOTALNUMBER of wells construction details.You may also attatrhadditiortalpages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 8-2 (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dterent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: e2 (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: {in.) 24A For Irtiectiatr Wens: Ire addition to sending the form to the addrubb in 24a
12.Well construction method: ,`
f�O T X y above,also submit one copy of this form within 30 days of completion of well
construction to the following: 1(i.e.auger,rotary,cable,direct push,etc.)
I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636Mail Service Center,Raleigh,NC 27699-1636
p�
I
13a.Yield(gpm) , 1 1) Method of test: P Ulm P . 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one,copy of this form within 30 days of
13h.Disinfection type: 1--T H- Amount: Lf a i_ 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 Revised 2-22-2016