GW1--03429_Well Construction - GW1_20230516

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
�T7INVS�J�M - ---- c---- -� 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
< ft. 1 b ft.
1-5 ]g U ft. ft. V'
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. 0 � ft. I N in. LI O 1 P V L
�:�'�^/2 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#Caw W�IUA J C v�l V FROM TO I 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 [DMunicipal/Public 0 ft. [t. in.
Geothermal(Heating/Cooling Supply) ffiesidential Water Supply(single) ft. ft. in.
Industrial/Commercial _ Residential Water Supply(shared) 18.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. ft. e A o 36b i w
Monitoring f Recovery ft. ft.
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 I)Stormwater Drainage
Experimental Technology InSubsidence Control
Geothermal(Closed Loop) ®li Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) I Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness solVruek type,grain size,etc)
y ft. ft.
4.Date Well(s)Completed: l Well ID#
5a.Well Location:T gip.
ft. ft. MAY i C,
(�t�E I�?�W �F�ST � ft. rt.
Facility/Ownerr� a '� f Facility ID#(if applicable)
20 f A)6T1+ERL HM05 I ft. ft. i stnnM:..:L1 . ^3` I:r.`<
Physical Address,City,and Zip
1 ,,r c 21.REMARKS
County Parcel Identification No.(PIN) :P M 0 L KV7 2 Z
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fat/long is sufficient) 22.Certification:
35.?o3 916IV N . ?T10 21 W
- -�ow;1�Qu •y-16-23
6.Is(are)the well(s)JRfermanent or DTemporary Signature of Cc red Well 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: GrYes 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(mown 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-I 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: A) 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@I00) construction to the following:
L
10.Static water level below top of casing: O (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: ` 4 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
n,�! ,J above, also submit one copy of this form.within 30 days of completion of well
/es+12.Well construction method: `�J 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
n
13a.Yield(gpm) Method of test: PUMP 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: T H Amount: Z 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