GW1--03336_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 DESCRIPTION
ft. , (> ft.
���
302_q (75-ft. fodL
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if ap livable
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
0ft. 60 ft. �in. L/L
Company Name `` ^r 16.INNER CASING OR TUBING( eothermal closed-loop)
2.Well Construction Permit#• g j 7 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.
17.SCREEN
Water Supply Well:
_ FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural IOMunicipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in,
:)Industrial/commercial Residential Water Supply(shared) 18.GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT ETHOD&AMOUNT
Non-Water Supply Well: 9 ft. ft. leg/P s /U
92
Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
_ 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage
Experimental Technology E3 Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Coolin Return) FROM TO DESCRIPTION(color,hardness sollf ock type, 'n size,etc.)
( g/ g ) �- Other(explain under#21 Remarks)
® ft. ft. V 2 G1
4.Date Wells)Completed: a Well ID# ft. ft.
Saa..Well Location: ft. ft.
L01 J192L ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. �^ ?L_6 v 1--.
f 177 L1,r�l, c Sin✓�
/� ft. ft. MAY 1 C 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.Certification:
N 78. 73k.232- W
6.Is(are)the well ^ P s) ermanent or Temporary Sign a of Certified Well C tractor Date
a&
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: [3Yes or RINo 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: / SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) 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 2@100') 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: SQ r$ (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
II above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: f'f�ti 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) Method of test:. O ° 24c.For Water Supply&Injection Wells: In addition to sending the form to
AA the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 4 Amount: 55 nAd4l o'c 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