GW1-2023-02342_Well Construction - GW1_20230331

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Y a2 I.!1 I � D,/�^ �,o -.__..--.-- 14.WATER ZONES ,
Well Contractor Name Lam` FROM TO DESCRIPTION
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if a vable
Water Wizards Inc FROM TO DIAMETER THICKNESS li MATERIAL
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#• FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) `U ft. ` ft. q in. 1 Q V C
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
( Agricultural DMunicipal/Public 0 tt. ft. in.
-_ Geothermal(Heating/Cooling Supply) ;/'residential Water Supply(single) tt. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
lrri ation FROM TO MATERIAL EMPL CEMENT METHOD&AMOLIXT
Non-Water Supply Well: tt' < n' PO('* A.v d 250i US
Monitoring f Recovery
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
- Experimental Technology DSubsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiltrock type,grain size,eta
2
4.Date Well(s)Completed: 7^1 lJ r 25 wen Ew
So.Well Location: ft. ft.
A 3Facilityy//O�err N�amec,, Facility ID#(if applicable) ft. it. _ I
LLB ��f��0Jl lcld - ���r � ft. ft. ift«•�,,.,,i ..i 7r;_ I i
Physical Address,City,and Zip ft. ft.
(� e_ M 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: /
(if well field,one laatt/flong is suuffficcient) }( 22.Certification: r7
6.Is(are)the well(s) Permanent or Temporary Si a of Certified Well Contractor Date
By signing this form,I hereby certify the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Aon
Yes or QNo with 15A NCAC 02C.0100 or ISA N C 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construcformation and explain the nature of the copy of this record has been provide 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: I,�/'� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: At/ (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 2@100) construction to the following:
10.Static water level below top of casing: I oo (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: I Q (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
` y above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: ��*r'`-A 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&Injection Wells: In addition to sending the form to
p the address(es) above, also submit one copy of this form within 30 days of
LI
13b.Disinfection type: Amount; •Sc) 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