GW1-2023-02340_Well Construction - GW1_20230331

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor
\Information: /l -
- - - ✓g SCN 1 lScf l �'{(' - - - - i 14.WATER ZONES
Well Contractor Name (� FROM TO DESCRIPTION
6 S72 l� I G3 ft. NO
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
Company Name O ft. 2 2 ft. r/q in. I GW(ID QV
16.INNER CASING OR TUBING( eothermal closed-loop)
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2.Well Construction Permit#• FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft. `J ft. in. SZ� �r
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
r Agricultural OMunicipaL/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) lgrResidential Water Supply(single) ft. ft. in.
IndustriaUCommercial DResidential Water Supply(shared) 18.GROUT
Itri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring E3Recovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery ( Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage
Experimental Technology Subsidence Control
.]Geothermal(Closed Loop) f_ Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal eating/Cooling Return) F Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hanta soll/mck type,grain sia etc.
ft. ft.
4.Date Well(s)Completed: ?-)+Z 3 Well ID#
5a.Well Location:
)LIM G fb)D ft. ft. MAR 3 207.9
Facility/Owner Name (� (� Facility ID#(if applicable)
Jnf 1 �GCM {�� iJl�`�OC� I` C, ft. ft. tis,_, , . . , . : .•. -. :� ;,,.,
Physical Address,City,and Zip ft. ft.
`I P_ 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:
3�. 512Go N :n L 1-7r,2 w l" 2-I 2�
6.Is(are)the wells) (Permanent or [3Tempt/rary Sfoature of Certified Well Ce c or Date
JT�'�� \,. By signing this form,I hereby certify tha he well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ]Yes or [:)No 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 constructr t:�to ormation 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: 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@20h0'and 2@100) construction to the following:
10.Static water level below top of casing: f ll (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: (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: &W construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY CWELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) J Method of test: AA 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: 14111 Amount: LZ completion of well construction to the county health department of the county
where constructed. i
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016