GW1--03925_Well Construction - GW1_20230612

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
°�� f ft. ft.
J��' -ft. ft.
I
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Iicable
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name
V ft. ft. I
to,rf in. $PZ—2_1 P 1/&
�,ta),� 16.INNER CASING OR TUBING( eothermal closed-loop)
2.Well Construction Permit it. Z�� FROM TO DIAMETER I THICKNESS I MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) M ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OM mcipal/Public 0 fL ft. in.
t,4 ees Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft. M in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Im ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. 3A," cp ai-re-
Monitoring [)Recovery ft. ft. P.
Injection Well:
ft. It.
Aquifer Recharge E]Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OI Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
( Aquifer Test IOStormwater Drainage ft. ft.
Experimental Technology I0Subsidence Control ft. ft.
Geothermal(Closed Loop) 'Tracer 20.DRILLING LOG attach additional streets if necessary)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
4.Date Welf(s)Completed: 57 W.H ID# 7ft. / ft.
5a.Well Location: ft. ft. eftiry SA
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Facility/Owner Name Facility ID#(if applicable) ft. ft.
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...
riC.3,�f.1�
Physical Address,City,and Zip �7{
. ft. I ,d O23
ft
✓/ 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutestseconds or decimal degrees:
(if well field,one lat/long is sufficient) 22,Ce do
t /J) //3 0 21 C/ 17,3
6.Is(are)the wells) 0 Permanent or Temporary Signahrr of Certified Well Contrac 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: Yes or o 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 10 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-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- (� (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: A) L-e-iil 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) lq-10 Method of test: ®[71f 12 �E� 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: 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