GW1--06736_Well Construction - GW1_20241112

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.W�Contractor Information: 1 j
14.WATER ZONES �. I
Well Contractor Name FROM TO DESCRIPTION
�1 u CT—Cr 70 ft. �p ft. 1Uo/it
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap linable)
Water Wizards Inc FROM TO DIAMETER THICKNESS/ MATERIAL
Company Name D it. 60 ft. / ! in. ,YO Pvi
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. ft. I in.
3.Well Use(check well use): ft it in.
Water Supply Well: 17.SCREEN ;.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 13 esidential Water Supply(single) fL rt. in.
Industrial/Commercial OResidential Water Supply(shared) 1&GROUT_ i
Irrigation FROM TO MATERIAL EMPLACEMENT Hi O &AMOUNT
Non-Water Supply Well: 0 fL GO fL LV',p— Ql / /rfn)/& .
Monitoring Recovery ft. ft f v'�,v t(tJ ^^��__YY/// 000���VV t�l '
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DI Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary) .
FROM TO DESCRIPTION(color,hardness,soiWroek type,grain size,etc.)
Geothermal(Heating/Cooling Return) [[/i Other(explain under#21 Remarks) ft. ft.4.Date Well(s)Completed: /q/o2-1 Well IDA A 3S— S Z.R , ft. ft. •• , - ,
Sn. O L cation: ft. ft. j' •,. (,.: ii_a , '•.-1 ..... !
0-1 tee. (11/CL/K ft. ft
NOV 1
Facility/Owner Name Facility ID#(if applicable) ft' ft. 2 i
q '70 Ofj-k... 5r0frze. 1Vli 4- o�`.�vlt ".
Physical
/Adddresss,,/City,and Zip
ft. ft. i fy:G;•4':<r,,
p-GJ V J r 21.R1VILRKS
,Q� /� �,,
County Parcel Identification No.(PIN) v ` /le / I J�1`,- ,re r /--t'ZfJ"'�iVlr/
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56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
ren
(if well fi ld,one Iai/long is sufficient) r 22.Certification: (
6.Is(are)the wells) ermanent or �I Temporary Signature of Certified Well Contractor: Date
By signing this form,I hereby certibi that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: i� es or ONo with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known'iv!!contraction information and explain the nature oldie copy of this record has been provided to the well owner.
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repair under#Ill 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 OW-1 is needed. Indicate TOTALNUMBER of wells GOnstnrcti°n details'You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface: • 5/0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths((fdderent(example-3@2000'and 2@100) construction to the following:
10.Static water level below top of casing: n `,bd2 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: G (AI ;in-)
24b For Injection.!Fells. In addition to sending the form to the address in 24a
�2 above,also submit one copy of this1 form within 30 days of completion of well
12.Well construction method: / -Cf construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,iUtiderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) O il
Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submitione copy of this form within 30 days of
13b Disinfection type: Amount: completion of well construction to the county health department of the county
where conittrueted:
Form GW-1, North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016