GW1-2023-02007_Well Construction - GW1_20230227

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Q.n �e� 'f �► 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
7 - l� 7 0 ft. 7 1 ft.
ft. I ) 6 ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells R LINER if licabk
Water Wizards Inc FROM TO DIAMETER T CKNESS MATE A
O ft. ft. in.
Company Name 16.INNER CASING OR TUBING eothermal dosed-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: PR MCREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OM Icipal/Public 0 ft. rt. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
IndustriaUCommercial Residential Water Supply(shared) 18.GROUT
Irr1 ation FROM I TO MATERIAL EMPLACEME METHOD& OUNT
Non-Water Supply Well: ft. ft. dl f-e 7
Monitoring Recovery
Injection Well:
rt. 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)
ss,
Geothermal(Heating/CoolingReturn) l Other(explain under#21 Remarks FROM TO DESCRIPTION(color,hardne s W�k tin size,etc.ft. ft.
4.Date Well(s)Completed: I `v Well ID#
ft. ft.
5a.WellLocation:
1
Facility/Owner Name 1` Facility ID#(if applicable)
,57 �JL�Or MDt�lfh ' 1 �� rt. ft. a
Physical Address,City,and Zip ft. ft.
21.REMARKS
County Parcel Identification No.(PIN) ,/1 •
5b.Latitude and longitude in degrees/ndnutes/seconds or decimal degrees:
(if well fiend,one laat/loonng is/sulfficient) 1 22.Certification:
AQ I a�(J b /1 N 7 9 3 ,5 t I W
6.Is(are)the wells) Permanent or r.. .r
rary Signatur Certified Well Contractor Date
BY signing this form,I hereby certify that the (s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13No 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 I 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 differem(example-3@201,0''a(nnd 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"+l 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
r above, also submit one copy of this form within 30 days of completion of well
12.Well constriction method: 1 �l r�I 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: M 24c.For Water Supply&Injection Wells: In addition to sending the form to
C r1 1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: J V y/,&f L 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