GW1--03446_Well Construction - GW1_20230516

Rint Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Water Wizards Inc 14.WATER ZONES
Well Contractor Name FROM TQ I DESCRIPTION
Taylor Often 130 f L U al
ft ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Bcable
4497-C FROM TO DIAMETER THICKNESS RIAL
�. fL I e
Company Name
16.INNER CASING OR TUBI G(geothermal closed-loop)
2.Well Construction Permit#: FROM TO I DL4LMETER I THICKNESS I MATERIA
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) fL 0 fL is �/� (JIjfv
3.Well Use(check well use): fL v fL in. JC lVJ t
Water Supply Well: 17.SCREEN
_ FROM TO DIAMETER I SLOT SIZE I THICKNESS MATERIAL
Agricultural QMunicipal/Public fL fL in.
Geothermal(Heating/Cooling Supply) EfResidential Water Supply(single) fL fL in,
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM I To MATERIAL EMPLACEMErJT METHOD&AMOUNT
Non-Water Supply Well: % Q fL f Pa u
I Monitoring Recovery fL fL
Injection Well:
ft fL
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage % fL
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM fL fL To DESCRIPTION color,hardness,soillo k t size,etc.)
4.Date Well(s)Completed: 'G�� 23 Well ID# % ft.
fL fL
Sa.Well Location:
On r I a )muw fL ft. MAY i g 7073
Facility/ —eery Name A Facility ID#(if applicable) fL ft.
�I vl � � G 1VA �lJ� % ft. In,u�r,�:�:;::.�i . t: ::�-�,:� �r,:�
Physical dress,City,and Zip R' ft
WWII 21.REMARKS
County 1 ll 1 1 Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latt/long is sufficient) 0 22.Certification:
�- D-- �q N 11.OS�U�S.� W �� ��l
6.Is(are)the well(s) Permanent or Temporary Signature ofCe ified ❑ ontractor Vat"e—�—"—
1 By signing this form I h reby certify that the well(s)Was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or [DNo with 15A NCAC 02 .0 00 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construct n 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 INSTRUCPIONS
t 1
9.Total well depth below land surface: ! D (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example and 2@I00) construction to the following:
10.Static water level below top of casing: (N A) 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: O) (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
�ULL 12.Well construction method: above,also submit one copy of this form within 30 days of completion of well
T�(i.e.auger,rotary,cable,direct pasty etc.) construction to the following:
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 Suoaly&Iniection Wells: In addition to sending the form to
r the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 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