GW1-2023-02325_Well Construction - GW1_20230331

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
✓
J� •eft. f�j ft. 3Q
,3c22-q—`'T
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a licable
Water Wizards Inc FROM TO DIAMETER THII�CKNESS MATERIAL
ft. ft. (0 in. ,>J •ZJ PVC_
Company Name
16.INNER CASING OR TUBING( eothermal closed-loop)
2.Well Construction Permit#: /v F�� W 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.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipal/Public 0 ft, fL in.
J Geothermal(Heating/Cooling Supply) , Residential Water Supply(single) ft. ft. in
Industrial/Commercial EIResidential Water Supply(shared) 18.GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. "Me I Al
2 C cAfrc
Monitoring ORecovery
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 [IStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
i Geothermal(Heating/Cooling Retumex IOther( plain FROM TO DESCRIPTION(color,hardn soll/rock e, to size,etc.)
• under#21 Remarks) ft. •�7 ft. �l�Cf��
4.Date Well(s)Completed: 3,fo-L3 Wel1ID# ft' / ft,
Sa.Well Location: ft. ft. Isr
Facility/Owner Name Facility ID#(if applicable)
z -��`flft. ft. MAR 3
Physical Address,City,and Zip / Y eL Z 7 03_�t
, ft.
©rt.,c P "1 _1119 �O 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s)pfermanent or Temporary Signature of Certifieriffell Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or 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: Q SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (J� (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 t@200'and 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„+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (D y (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: �gr? irvl 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) 3e Method of test: v 24c.For Water Supply&Injection 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: of Amount: O merit�s 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