GW1--06604_Well Construction - GW1_20241112

, Print Form '
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
• J;9 ii e i (J-r-�/i1 .114.WATER TOEDESCRIPTION, iI
Well Contractor Name
2_,e/-i4 21c ft' 2?�? * /
ft. n
NC Well Contractor Certification Number 15.OUTER CASING(for multl-cased wells)OR LINER(if ap licable).
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
0 R. 2,5-tl. 6,j in.
Company Name `7
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 1O
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural (DMunicipai/Public ft, ft. In.
Geothermal(Heating/Cooling Supply) 1 fG1 idential Water Supply(single) rt. ft. In.
Industrial/Commercial Di Residential Water Supply(shared) IR.GROUT
Irrigation FROM ' TO ' MATERIAL 'EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 2-5 tt- -j e"Ho
re �' p d,L
Monitoring Recovery ft. ft.
Injection Well: I• i t tw 204 lGLt
ft. ft. S0®!1S
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery QI Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft• N- ,
Experimental Technology }Subsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Hearin Conlin Return FROM TO DESCRIPTION(Odor,hardness,soil/rock type,grain size,etc.)
g/ g ) DI Other(explain under#21 Remarks) 0 ft- 7 fL ®f�e;b3„^erQ
e."I
4.Date Wells)Completed:7.7�Zv Well IDA 7 ft I c ft, _se -i
5a.Well Location: l S ft. Z Y('ft & i.`i rod(
Facility/Owner Name Facility ID#(if a licable) ra ft.
k
= 7. _ cI17 1
.3/,® ilem'.S,sl c.,r , 0„ Cr t- Np,,r- ili- ft. ft. rt
Physical Address,City,and Zip ��7 L �r ft• ft. N Q V 1 v t0 2T
t / /4 21.REMARKS i'sR
County Parcel Identification No.(PIN) r,- ia4.r'-='.:°J
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certitica' n:
/3k0 090576 N - 70,610 39 7 w Certifi3 -13'
er Tate-6.Is(are)the well(s)0ermanent or OTemporary
By signing this form,I hereby cert fy that'the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DI Yes or IIKO with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If thir is a repair,fill out known well construet/am Faj6mraiicn and erplaiie 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 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 TOTALI3UMBER of wells construction details.Yon may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
Z140
9.Total well depth below land surface: ( ) 24a.For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdeerent(example-3@200'and 2Qa 100 construction to the following: I.
10.Static water level below top of casing: (ft.) Division of Water Resourc I,Information Processing Unit,
Ifwater level is above casing,use"++0p 1617 Marl Service Center,'Raleigh,NC 27699-1617
11.Borehole diameter: l 1 (in.) 24b.For Injection Wells: In addition I t 1 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: ko i
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
I ,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: i ,LJPI/LtS)‘24c.For Water Supply&Infection Wells: In addition to sending the form to
J ....7- the address(es) above, also submit ode copy of this form within 30 days of
13b.Disinfection type: `% ( I") Amount: /5-(rrly)f .l4 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 ti Revised 2-22-2016
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