GW1-2023-01964_Well Construction - GW1_20230227

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
(�
1 6-1 2
NC Well Contractor Certification Number 15.OUTER CASING for mutti-cased wells OR LINER if a licabk
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name J (J in. ,v
16.INNER CASING OR TUBING(geothermal 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. 3 ft. in. 504 /
3.Well Use(check well use): ft. ft. in• '7
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipaVPublic 0 ft• ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) n• ft in.
Industrial/Commercial Residential Water Supply(shared) I&GROUT
Irfl ation FROM I TO MATERIAL EMPLACEMENT MET OD&AMOUNT
Non-Water Supply Well: ft. Oq ft cW l nd e
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3StormwaterDrainage It• ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soiUrock type,grain size etc.)
ft. ft.
4.Date Well(s)Completed: �a-Z Well II)#
Sa.Well Location: D• ft. -
/$:,yaO ft. ft. _
Facility/Owner Name Facility ID#(if applicable)
:2 0 7 Old nx Ford NU
Physical Address,City,and Zip
Dsg Y v.J 21.REMARKS
County 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:
�,G, •1�, 21 gS3 N - 7s- s ZI 45 2g W
6.Is(are)the well(s) Permanent or Temporary ature of Certified Well Contractor Date
�yt By signing this form,I hereby certify the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: y,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 constru`_Ilonn 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: Q/"� SUBMITTAL INSTRUCTIONS9.Total well depth below land surface: 1 L/ M-) 24a• For All Wells: Submit this form within 30 days of completion of well
For multiple wells fist all depths if different(example-3 rCt 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"+" 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
D�i Q� above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: �(7 —` 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: Gow 24c.For Water Suouly& Injection 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: 30 7 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016