GW1-2023-02323_Well Construction - GW1_20230331

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Name
bbb FROM TO DESCRIPTION
loom
( .l I /Z_ — ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in. MV S�A
Company Name 16.INNER CASING OR TUBING reothermal closed-loop)
2.Well Construction Permit A 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•17.
` _v
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q
ft. ft. for OAA Oc f-
Monitoring I Recovery
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 E]Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) F1 Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soittrock type,grain size,etc.
ft. ft.
4.Date Well(s)Completed: 7-23 Well ID#
5a.Well Location:
Facility/Owner Name Facility ID#(if applicable) ft. ft. MAR a
1 7
1?2
?r1i_i L•f .. ❑ ;''i_._;:^„ ? fi:i
Physical Address,City,and Zip ft. ft. �-,�,;;•� -�,.;
(ti+� + 1 0 ^ 1 7/I - cR 21.REMARKS - J
County Parcel Identification No..((PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if welll/l field,one lat/long is sufficient) 22.Certification: /
(o• Sd N 7q• l O��W
6.Is(are)the well(.) Permanent or Temporary Sigfinfure of Certified Well Contractor Date
//0 By signing this form,I hereby cerlijy i the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or 'ONo with 15A NCAC 02C.0100 or 15A MAC 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 different(example-3@200'and 1@100D 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: f N (in) 24b.For Iniection 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: s y1 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) to Method of test: ky"12 24c.For Water Supply&Injection Wells: In addition to sending the form to
'A the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: "/,.�0 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