GW1-2023-02535_Well Construction - GW1_20230406

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: j
1.Wt�ell Contractor Information:
�`�I 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
� ft. G.
GI J ft. vV v ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if a licable)
Wiz
ards izards Inc FROM I TO DIAMETER THICKNESS MATERIAL
ft. U ft. f in. (yn-(l f� [_
Company Name 16.INNER CASING OR TUBING( eothermal closed-loop)
2.Well Construction Permit#: 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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3M cipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. t �'_ as
U
Monitoring ewvery
Injection Well:
ft. ft.
Aquifer Recharge i Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage
Experimental Technology I3Subsidence Control
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks FROM To DESCRIPTION
hardness soiVrock t fain size etc.)
ft. ft.
i
4.Date Well(s)Completed:t=IJ Well ID# ft. ft.
5a.Well Location: l J1 ft. ft. le_%.-,L... V ._..1-1,1
( %tom ft. ft. APR 3 20?3
Facility/OwnerName Facility ID#((if applicable) ft. ft.
s�� co-3cy4., v L �V�i ,i(�jl'J� I�/C. ft. ft.
Physical Address,City,and Zip
21.REMARKS County Parcel Identification No.(PIN) J//
I (- ' ill
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ",,l 0 r
(if well field,one lat/long is sufficient) 22.Certification:
1 1 N ?g'3=e 2A 111 W Y� Sin
6.Is(are)the well(s) i-'Permanent or Temporary Signature of Certified Well Contractor Date
� By signing this form,I hereby certify that the we/l(s)was(were)constructed in accordance
7.Is this a repair to an existing well: L�J•w or [3No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fr11 out gown 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: (� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: D`'� 6 (R•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 a200'and 2@I00) construction to the following:
10.Static water level below top of casing: nG 19, (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: U (in.) 24b.For Infection 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: 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(gm) Y Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
I-- the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: X Amount: ��� completion of well construction to the county health department of the county
where constructed.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resource' Revised 2-22-2016