GW1--03327_Well Construction - GW1_20230516

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
�At�n f/ fyt 14.WATER ZONES
T FROM TO DESCRIPTION
Well Contractors Name ft. ft.
o a 2L4- ft. ft.
NC Well Contractor Certification Number 1 LITER CASING for multi-cased wells)OR LINER if a livable)
CK
Water Wizards Inc FROM TO DIAMETER THINESS MATERIAL
ft. I ft. JW in. / 4/0
P
Company Name
16.
n GK
2/ FROM
CARING OR TUBING( eother at closed-moo )
2.Well Construction Permit#: 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 EI]M mcipal/Public 0 it. ft. in.
:)Geothermal(Heating/Cooling Supply) sidential Water Supply(single) et. et. in.
Industrial/Commercial DResidential Water Supply(shared) ls.GROUT
Irrigation FROM TO MATERIA EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. f/ / -5 I
Monitoring Recovery ft. ft. IId
Injection Well: ft. ft. a O
Aquifer Recharge Groundwater Remediation
uifer Storage and Recovery 1R SAND/GRAVEL PACK(if A livable
A q a ry QISahRlty Bawler FROM TO MATERIAL EMPLACEMENT M THOD
- Aquifer Test L 3Stormwater Drainage
Experimental Technology OSubsidence Control tt. rut.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) FlOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,solUrock type,grain sim,etc.)
ft. ft. v
4.Date Well(s)Completed: - wen ID# rut. ft.
5a.Well Location: ft. [t.
Facility/Owner Name Facility ID#(if applicable) ft. ft. � �•�
ZD$/ .— � "'lc... Lt'�.�. H-1 !1S/°clanMl., rut. tt. 1 I 1 it 2023
Physical Address,City,and Zip ft. ft.
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certiti tion:
AS w
'/'A.? z
6.Is(are)the well(s)&Perruanent or OlTempo;0/
Si ature of Certified Tell Contrac or Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or with 15A NCAC 01C.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 I 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: 119V (ft.) 24a. For All Wells: Submit this form w'hrn 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: _ (ft.) Division of Water Reson��r//1 es,.Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: `�y�(in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
// above, also submit one copy of th's form within 30 days of completion of well
12.Well construction method: Ak-4-N construction to the following: -- '
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resou s,Underground Injection Control Program,
FOR WATER SUPPLY nWELLS ONLY: /� 1636 Mail Se 'ce Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 Method of test: 1210 w'~ '14c.For Water Supply& n'ection Wells: In addition to sending the form to
the address(es) above, alsoljubmit one copy of this form within 30 days of
13b.Disinfection type: Amount: &A.h C 07 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