GW1-2023-01965_Well Construction - GW1_20230227

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
�G�n n ,n 10.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
I i-f ft. W ft.
NC Well Contractor Certification Number 15.OUTER CASING for muitl-cased we OR LINER if licabIe
Water Wizards Inc FROM TO DIAMETER I THICKNESS MATERIAL
ft. I ft. in. �
Company Name 16.INNER CASING OR TUBIN (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. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3M cipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in
Industrial/Commercial Residential Water Supply(shared)
Iti.GROUT
Irrl ation FROM I TO MATERIAL EMPLACEM METHOD&AMOUNT
Non-Water Supply Well: [t. I tt.
Monitoring Recovery
Injection Well:
tt. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,wf/r k type,gmin size,etc.)
tt. ft.
4.Date Well(s)Completed: J Well ID#
5a.Well Location:
Lor1 Noviarl ft.
Facility/OwnerRNa/me Facility ID#(if applicable) `
Physical Address,City,and Zip
bar 1i ary) 21.REMARKS
County Parcel Identification No.(PIN) INs la I I fvA `
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if welleId``,one lat/long is sufficient) t 22.Certification: 1 l
3 1 ' 1311 N 79°S3 U W
6.Is(are)the well(s) Permanent or [3Temporary Signatu&6f Certifie Well ont'actor Date
By signing this form,1 hereby certify t the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: es or QNo with 15A NCAC 02C.0100 or ISA NC 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-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: C 1 (ft.) yqa• For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'an(dd22@100') construction to the following:
10.Static water level;below top of casing: 17 \ 1 (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: l9 ` (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
a above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: ��,� 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: p 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 1 �t 24c.For Water Sanely& 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: 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