GW1--06738_Well Construction - GW1_20241112

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1
1.Well Contractor Information: ,
Lr c Cook :,14.WATER ZONES .,,
Well Contractor Name FROM TO DESCRIPTION
4 6 7 7 (-� s to ff. i ft. 3j 6.PM
ft. Tt7 ft 1
NC Weil Contractor Certification Number 15.OUTER CASING(for multi-cased:wells)OR LINER(ifap licable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL -
Company Name
0 ft (b3 ft. If)% , in- sD R a 1 Pvc
16.INNER CASINGOR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO u DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,Comm),State,Variance,etc.) ® ft. 8.0 ft il in. Sc 1J D if[`�a plc,
3.Well Use(check well use): ft in. V
Water Supply Well: ',17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
I Agricultural OMunicipal/Public rt ft. in.
*Geothermal(Heating/Cooling Supply) ,Residential Water Supply(single) ft. ft In.
II Industrial/Commercial DResidential Water Supply(shared) IS.GROUT - 1
r Irrigation FROM s TO t mamma r EMPLACEMr2'TMETHOD&AMOUNT
Non-Water Supply Well: t) ft* (O 3 it j(140k, q VQ. 4-t't��' ;',1M'Monitoring Recovery ® ft. TO ft /j �J Place ffsbDJ
1 r
Injection Welt: /V C
ft. ft. 7 a�50 ibi P REQ
• jj�Aquifer Recharge Groundwater Remediation '
• 19.SAND/GRAVEL PACK(if applicable)
RI Aquifer Storage and Recovery Dt Salinity Barrier FROM TO MATERIAL , EMPLACEMENT METHOD
(M Aquifer Test IDStormwater Drainage ft. ft'
Experimental Technology OSubsidence Control ft. ft ;'
('Geothermal(Cfnced Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary) ,,,.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soisoil/rock type araia srze etc.)
ji 0
Q 0 ft- An vtr
4.Date Wells)Completed: 1-1I dr�y Well IDI A 7S.-3114 a n .25" ft- i; C.Ia 1,
5a.Well Location: oC,S• ft 1 IS it 6.ce Ro-r.k.. .
Char le_S Dau:S
Facility/Owner Name Facility 1D#(if applicable) ft. ft NOV, 1
2024
Sc 7 6Z,ber+ Gen 4ry l T:mbecIGke, ft. it ft ft. ;:
Physical Address,City,and Zip
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Person 21.REMARKS i .
County Parcel Identification No..(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one lat/long is sufficient) 22.Cer'tilication:
N W , yr77P 9_11_aLi
6.Is(are)the well +s) Permanent orTemporary Signature o e well Contractor Date
By signing this form,I hereby certIb,that the well(s)was(were)constructed in accordance
7.Is this a repair to an pxicting well: 0I Yes or PIo with ISA NCAC 02C.0I00 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill end bwamnullecxv n4.,,,....t:,..eaade Iran reredithe cojtv ofthIs record has beenprovided to jim 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 pageto provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTALNUMBBR of wells construction details.You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS ,
9.Total well depth below land surface: I"0 (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@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 Ci nter,Raleigh,NC 27699-1617
11.Borehole diameter: 1 {in.) 24b.For Iajeetiene Wens: Ls additiros to sag the fame to the address in 24a
rl, p above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:etc.)
t'- n r►/ 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) 30 Method of test:. OLM4itean, 24c.For Water Supply&Iniectionc Wells: In addition to sending the form to
1�..�1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: P9'1 1i Amount 07i completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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