GW1-2023-02008_Well Construction - GW1_20230227

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Name o FROM TO DESCRIPTION
c ft. q ft. 7 m
NC Well Contractor Certification Number 15.OUTER CASING for could-cased wells OR LINER if applicable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. I in. LppI
Company Name tw
16.INNER CASING OR TUBING anal closed-1
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft, It. in. L7
3.Well Use(check well use): -ft. 11L �'V
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) ixesidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrl ation FROM TO MATERIAL EMPL EMENT METHOD&AMOUNT
Non-Water Supply Well: ft. rt. 0(tJAAa
Monitoring Recovery ft. ft.
Injection Well:
ft. n.
Aquifer Recharge QGroundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage rt. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) QTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) rJOther(explain under#21 Remarks)J
FROM TO DESCRIPTION color,hardness,wfl1rmk type,gmin size,etc.
tY. ft.
4.Date Well(s)Completed: 2— -7 Well ID# -
5a.Well Location:
sad
Facility/Owner Nine Facility ID#(if applicable)
Physical Address,City,and Zip ft. ft.
f OV, ,- O^ PHO - 2�C) 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:
i3L .--,)2 Z t3,54-9 N 7 ! I C) W
2- -7 -Z3
6.Is(are)the well(s)OPermanent or Temporary Si a of Certified Well Contrutor Date
By signing this form,1 hereby certify that the K(s) (were)constructed in accordance
7.Is this a repair to an existing well: Yes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
1f 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 t GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBNEITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 d (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
1f water level is above casing,use"• " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1, (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
12.Well construction method: �C7�btf� 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&Iniection Wells: In addition to sending the form to
`J the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: T� rl Amount: �20-7 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