_Well Construction - GW1_20230315

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
j has -�yy 14.WATER ZONES
���000 FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
�I 51Z - L
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Water Wizards Inc FROM L
DIAMETER I THICKNESS MATERIAL
tt. ft. in. I V
Company Name
j d I %`)�-2 16.INNER CA 1NG OR TUBING( eothermal c osed-loo )
2.Well Construction Permit#: (/ FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. O ft. L in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agicultur"I DMunicipal/Public 0 ft. ft. in.
NGeothermal(Heating/Cooling Supply) WResidential Water Supply(single) n, ft. in.
Industrial/Commercial Residential Water Supply(shared) GROUT
� IrriRation FROM TO MATERIAL 1 EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: [t. ft OCT t/1Ci
Monitoring EiRecovery ft. n.
Injection Well: ft. ft.
Recharge OGroundwater Remediation
_ 19.SANWGRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft. ft.
Experimental Technology E3Subsidence Control ft. ft.
Geothermal(Closed Loop) E]Tracer 20.DRILLING LOG attach additional sheets if necessa
so
i �Geothermal(Heating/CoolingReturn) I ! Other(explain under#21 Remarks) FROM ft. TO ft. DESCRIPTION(color,hardness lVrock type,grain size,etc.
4.Date Well(s)Completed: 23Well ID# ft. ft.
5a.Well Location: tt. ft. in
1�0`v IC L 'Igd`P4 ft. ft.
MARft. ft. i 41
LI.LJ
Facility/OwnerName (� 1 Fa1c�i]Llitya ID#(if
�apnplicalbll/e�)nI
3I J[[ 07-10� )R,,L �Y�qe , l<i YW�`1l ft. ft. In,�•, ,:: ;1 :.';';, ^... ,.,�I�c:..L
Physical Address,City,and Zip
ft. ft.
No ✓1 t 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latllong is sufficient) 22.Certification:
y-)w N - 73; 989(5 571 W -2�
6.Is(are)the well(s)O
Permanent or Temporary Sign ure of Certified Well Contractor Date
By signing this form,I hereby certify that tile
well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Mes or DNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
If this is a repair,fill out known well constructs Jninfarmlion and explain the nature of the copy of this record has been provided 10 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: (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@100D construction to the following:
10.Static water level below top of casing: to Division of Water Resources,Information Processing Unit,
If water level is above casing,use
rr"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: b (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
fJ 12.Well construction method: ,t� above, also submit one copy of this form within 30 days of completion of well
tw
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
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: 24c.For Water Supply&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: Amount: Sl)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