GW1--03450_Well Construction - GW1_20230516

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Name FROM TO DE/SCC/RIPTION
Ce—1 ,�� 1 RD ft. 1 ft. L 4 6vl
/`J/ ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a licable)
Water Wizards Inc FROM I TO DIAMETER I THICKNESS I MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING( eothermal closed-loop)
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) V ft. ft. in.
3.Well Use(check well use): ft. ft. in. +fib
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:)Agricultural [JMunicipal/Public 0 ft. ft. in.
i Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Im ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. /l� ke /C+!?
Monitoring Recovery ft. ft. v
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if a licable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
---Experimental Technology D Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) FI10ther(explain under#21 Remarks) FROM ft. To DESCRIPTION color,hardness,soil/rock type, In siu,etc.
1 ft.
4.Date Well(s)Completed: ?� O Well ID# S r ` ft. ft.
SaWell Location:
6
Facility/Owner
/Nara �,cc Facility ID/#(if appplliccable) ft. ft. L C l'23
Physical Address,City,and Zip
ft. ft.
21.REMARKS
County v—,V ` Parcel Identification No.(PIN)
c
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one lat/long is sufficient) 22.Certification:
-E rl , Cg WCam
6.Is(are)the well(s) ' nfanent or OTemporary Signature of Certified Well Contractor Date
� By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
V�,,,
7.Is this a repair to an existing well: 1y' or DNo 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 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: /J SUBMITTAL INSTRUCTIONS
j
9.Total well depth below land surface: ( l./,/o (ft.) 24a, For All Wells: Submit this form within 36 days of completion of well
For multiple wells list all depths if different(example-3 tet 200'and 2Q100) construction to the following:
10.Static water level below top of casing: (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: (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: V 12,r—�'t 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) G Method of test 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: 6 t Amount: completion of well construction to the county health department of the county
Where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016