GW1--06676_Well Construction - GW1_20241108

1
Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I
1.Well Contractor Information:
&.C CG.C1 k 14.WATER ZONES {
Well Contractor Name FROM TO I DESCRIPTION
CIO ft. 92 ft. I&Phi
z17 A olioNC Well Contractor Certification Number 15.O ft. CASING
G ft tl� dTe�`p _.
t OUTER CASING(for multi-cased wells)ORLINER(if ap licable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL '
Company Name O fL 4e ft. 6 yy in. St)R.21 P Vic
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable wetl 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
Agricultural OM cipal/Public ft. ft. ha
Geothermal(Heating/Cooling Supply) ,Residential Water Supply(single) fL ft. in:
Industrial/Commercial DI Residential Water Supply(shared) lg.GROUT
Irrigation FROM ' TO ' MATERftL 1 EMPLACEMENT METHOD&AMOUNT
(0
Non-Water Supply Well: ft. .2 fr fL ' r toleft3 f C L }},,��
ek 4 d rkl i-e_t A,
Monitoring IDRecovery ft. ft ti_ cy $®e) 65
Injection Well:
ft. ft.
Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery EllSalinity Barrier , FROM TO MATERIAL' EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft. I
Experimental Technology 0 Subsidence Control ft. ft•.
Geothermal(Closed Loop) °Tracer 1 20.DRILLING LOG(attach additional sheets if necessary) .
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) , FROM TO DESCRIPTION(color,hardness ash/rook type grain size etc.)
0 tL 3 fL ever kttrefE,f1
4.Date Well(s)Completed:10-16-l Well ID#- ' 3 ft' ©a l ft � day 4- ,ham(
Sa..Well Location: vC t ft 1+ ' ca.ild Sine.Y__
uarc,oJ Kelly :9a ft. LO0 f &ray ao4k.
Facility/Owner Name Facility lDit(if applicable) - ft. ft.
'7301 & dock. ii_ g1,ex.",4- 02 7g,3 ft. ft.
Physical Address,City,and Zip ft. ft. i ;
a�G�i W 1 I I�raC 21.REMARKS a ti NOV/ •A.. % a_ -`
County Parcel Identification No.(PIN) 'r U 0 8 20,;
n V 24
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification: Ifi`'3x,c. • i .
_ ``mil ''.f'�r'•.c,'•; tWi'!i.
S 27 I3I21 N 71�5;t34,L0-131I V w Ll,..' i.,•13 ^
/1� u I y
6.Is(are)the well(s) rmanent or fI Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certiry that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ()Yes orio with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known nrll cwrstrurriotr infarmrrtioR and esp&rin the whirr ofthe 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 I.GW-1 is needed. Indicate TIYTAL131M3BR of wells ennstructian details.You may also etta'r h additional pales if neeeeraty.
drilled: SUBMITTAL INSTRUCTIONS ',
9.Total well depth below land surface: d 0 (ft-) 24a. For All Wells: Submit this�fotm 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:
10.Static water level below top of casing: (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: et,Yir (in.) 2412 For faiectimr Wells: hr addit ore ltr seeding ng 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:A,fRe)-ksryconstruction to the following: j
(i.e.auger,rotary,cable,direct push,etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLYt WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I Ie2 &Pim Method of test:pp p`�� sending 13a.Yield(gpm) 171Dt:�1,'1 a�t'11;i� 24c.For Water Supply&Iniection Wells: In addition to the form to
t , the address(es) above, also submit;one copy of this form within 30 days of
13h.Disinfection type: 14111 Amount: i C)? completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016