_Well Construction - GW1_20230310 (63)

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
1
Well Contractor Name
�1 FR TO DESCRIPTION ft. )04 ft. I Z P
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if applicable)
Water Wizards Inc FROM I TO I DIAMETER THICKNESS MATERIAL
ft. ft. fin. a\ Ul
Company Name -''
16.INNER CASING OR TUBING( eothermal clo loo
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. G L ( ,
3.Well Use(check well use): ft. ft. in, v
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
NAgricultural [Municipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
Industrial/Commercial frResidential Water Supply(shared) 18.GROUT
lrrip,ation FROM I TO MAJERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. 6f WL
( Monitoring Recovery
Injection Well:
ft. ft.
Aquifer Recharge 0Groundwater Remediation
_ 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,solUrock type,grain size,etc.
4.Date Well(s)Completed: G Well ID#
Sa.Well
Location`: MAP,
�Ol LI j ft. ft. ivli-If,
IIr
Facility/Owner Name J Facility ID#(if applicable) ft. ft. J
iC-, -
0
Physical Address,City,and Zip �` ft. ft.
, fir, ell 21.REMARKS
County V V V�/ I Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is/sufficient) 22.Certification:
`y /� r F7�� N _ I P W
6.Is(are)the well(s) Permanent or OTemporary Signfifure of Certified Well Contractor Date
,,,,�{{({''' By signing this form,I hereby certify tha the he well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: I Yes or DNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construct on information and explain the native 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 TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 120 A) 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: �U (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-) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
��f 1 r t t above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: �t11i1 V 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) v Method of test: 24c.For Water SunDly&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: gT14 Amount: (�-S b Z 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