_Well Construction - GW1_20230315 (14)

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Informaation:
-S'l/s UY) Gi+n i hAA 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
�
NC Well Contractor Certification Number I&OUTER CASING for mWli cased wells OR LINER if a livable
Water Wizards Inc FROM TO D1AME ER THICKNESS MATERIAL
ft. ft. 6) in. ar V
Company Name 16.INNER CASING OR TUBING thermal closed-loop)
2.Well Construction Permit#: r) VL FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in. S V r
3.Well Use(check well use): ft. ft. in. �l �W
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipaVPublic 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. g in,
Industrial/Commercial Residential Water Supply(shared) I&GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT MET OD&AMOUNT
Non-Water Supply Well: ft. ft. PLOY- - ( QV'fP'
Monitoring Recovery
Injection Well:
ft. rt.
Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Coop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarksj
FROM TO DESCRIPTION color,hardness,wfllro k type,gmin size,etc.)
ft. ft. t
4.Date Well(s)Completed: I- 22.23 Well ID#
Sa.Well Location:
Facility/Owner Name Facility ID#(if applicable) B• ft.
023 I aya i e Aills Q.
Physical Address, and Zip
,� ) 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwelll field,one IaUI{ /�ong is sufficient) �/j�!� 22.Certification:
36JI � !0 N 1 . A2 /`1 W
6.Is(are)the well(s)OPermanent or OTemporary 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: Yes or QNo 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' 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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled: (� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 (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,
If water level is above casing,use"+" rr ,, 1617 Mail Service Center,Raleigh,NC 27699-1617
`
11.Borehole diameter: I (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Qi, above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: "1 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(,-pm)_ Method of test: 4 m 24c.For Water Snnoly&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: J 0 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