_Well Construction - GW1_20230310 (73)

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
AfUJA'& 14.WATER ZONES
Wel Contractor Name FROM TO DESCRIPTION
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Water Wizards Inc FROM TO DIAMETER TCHI(C�KNnESS MATERIAL
ft. ( ft. in. JV K
Company Name
16.INNER CASING OR TUBING eothermal 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. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) 52esidential Water Supply(single) g• n• in.
:)Industrial/commercial Residential Water Supply(shared) 18.GROUT
71 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring Recovery
Injection Well:
Aquifer Recharge QGroundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery r3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stomlwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color h soil/rock t n size etc.
ft. ft.
4.Date Well(s)Completed: ' Well ID# ft• ft•
5a.Well Location:
Facility/Owner Name Facility ID#(if applicable) B• ft.
l ft. rt.
Physical Address,City,and Zip it. ft.
&(� �� 21.REMARKS
County, Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) (( U 22.Certification:
3S° rJi�1,�3" N "IC30� '1'J 1 '/ yj" Wj
6.Is(are)the well(s)DW--11-ent or OTemporau Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: -- or ONo 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 construction information and explain 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-i is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: ISUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 9 o (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:
re /
10.Static water level below top of casing: b (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"-l"( 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: h /4 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
^( above, also submit one copy of this form within 30 days of completion of well
.Well constriction method: , 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) Method of test: aA A4,/ 24c.For Water Supply&Iniection Wells: In addition to sending the form to
11 II ff the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 14 F+ Amount: �iG 2L-_4_ completion of well construction to the county health department of the county
where constructed.
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016