_Well Construction - GW1_20230315 (5)

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
C. CnX C " 14.WATER ZONES
Well Contractor Name J
FROM TO DESCRIPTION
�[ft. 1 ft.
v ft. fob,
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if a livable
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
4.
ft. ft. in. aW S 1
Company Name
16.INNER CASING OR TUBING( eotherma]closed400
2.Well Construction Permit#: W Z V ^ 00(1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft. ft. 'in. C/)Lr/ v
3.Well Use(check well use): ft. ft. in. �• 17
Water Supply Well: 17.SCREEN
FROM I TO I DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Publicf. . in.
Geothermal(Heating/Cooling Supply) ,Residential Water Supply(single)
= Industrial/Commercial DResidential Water Supply(shared) is.GROUT
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. a ft. ` 041
:)Monitoring CIRecovery
Injection Well:
ft. ft.
Aquifer Recharge 'Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
I. Aquifer Test [3Stormwater Drainage
I Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM To DESCRIPTION color,hardness soluwck type,grain size,etc.
ft. ft.
4.Date Wells)Completed: ±!YL Well ID#
5a.Well Location:
a.s 1A � ft. ft. L
AAA
(
Facility/Owner Namer `, ,� (]Facility ID#(if applicable) ft. ft.
Stu V&Ve ONtif.) K a. �/� ►� ft. ft. iris• iu: tl i�� A�t iti Y
Physical Address,City,and Zip
©f 'C n• 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latflong is sufficient) 22.Certification:
-3G. 111 440� N - ?G a.5 o kZZZ W 2ti_ 23
6.Is(are)the well(s)OPermanent or Temporary Sign o Ce ed Wenconveror Date
By signing this form,I hereby certify that 4.
s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or [:)No with 15A NCAC 02C.0100 or 154 NCAC 0 .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-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@100) construction to the following:
10.Static water level below top of casing: k C) (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: 6M (in.) 24b.For Injection 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
�-y�]
12.Well construction method: 1 � As smA 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: 24c.For Water Supply&Infection 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: ���� 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