GW1-2023-01970_Well Construction - GW1_20230227

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
�rCA-K J a �r' l� r 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft.
NC Well Contractor Certification Number
15.OUTER CASING for mold-cased wells OR LINER if applicable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
S G
Company Name
40
16.INNER CASING OR TUBING eothermal 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. [t. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3M Icipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) esidentiai Water Supply(single) ft. ft. in.
Industrial/Commercial [3Residential Water Supply(shared) GROUT
Irrl ation FROM I TO MATERIAL i EMPLACEME METHOD&-AM UNT
Non-Water Supply Well: ft. ft.
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
t9.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
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,heraa sowrmk type,grain size,etc.
ft. ft.
.J
4.Date Well(s)Completed: 3 Well ID#
Sa.Well Location: ft• ft. r
J 'a.1('�r� �a r r ►s ft. ft. - ' �C J
Facility/Owner Name n Facility ID#(ifapplicable)
I a� �� 1 p rV i 1� �s^' t
Physical Address,City,and Zip
6 _ il�� REMARKS
1W� 1�
County Parcel Identification No.(PIN) r�
t
5b.Latitude and longitude in degrees/mivates/seconds or decimal degrees:
(if well field,one lat/ ng i's-ssufficient) ((� C.� 22.Certification
rr__ d,� :
6.Is(are)the well(s) Permanent or Temporary Si ure of Certified Well Contractor Date J
By signing this form,I hereby certify that well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: bes or [3No 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 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: (' SUBMTTTAL INSTRUCTIONS
9.Total well depth below land surface: V� (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 t0 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: G (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
O "12.Well constriction method: above, also submit one copy of this form within 30 days of completion of well
7
.e.auger,(i ,g rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUP Y WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) S r M Method of test: �\J AA 0 24c.For Water Supply& Injection Wells: In addition to sending the form to
,d{ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: l) 7i 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