GW1--03951_Well Construction - GW1_20230612

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
J Gi h a� t� 14.WATER ZONES ~
Well Contractor Name FROM TO DESCRIPTION
:30,2—q-/1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if ap licable)
Water Wizards Inc FROM TO DIAMETER THICKNESS IATERIAL
Company Name 6 ✓ri l
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: ���� vfJ Ofl ��"/ �GO � 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.
Water Supply Well: 17.SCREEN
_ FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []MunicipaUPublic 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) D(tesidential Water Supply(single) f.. ft. �•
IndustriaUCommercial DResidential Water Supply(shared) Is.GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring f Recovery ft. ft. 1pk
i
Injection Well:
ft. ft.
AquNer'Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach additional sheets if necessary)
so
- Geothermal(Heating/Cooling Return) _ Other(explain under#21 Remarks) FROM ft. TO tt. DESCRIPTION(color,hardness, 11/rock t she,etc.
r L)if r- "
e
4.Date,Well(s)Completed:T Well ID#
7 ft. ft.
Sa.Well Location: t. ft• y
y�h-C l ft. ft.
/7®v"GS
Facility/Owner Name Facility ID#(if applicable) ft. ft. N f!1—1'�
�(��SY1t��S .�C.i. �1.tT�(t /�'1. �/� /��-- ft. ft. �....r K-e.•ar'
Physical Address,City,and Zip �7�—/ ft. ft. 1 ti a 2023
—I 21.REMARKS
eS-�Oo/1 Inlvfrr*Q- cn Ln.1
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) �i, 22.Certification: -
36 , 32095�/ N — 790 102L 2/ 6, w
6.Is(are)the well(s) —ent or Temporary tgna a of Certified WeIT-Cofift1dor 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: E]Yes or io 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: u 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 1f di fferent(example-3@200'and�2@1100D construction to the following:
10.Static water level below top of casing: `7 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
/1 f f� above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: !� i� 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: 61adi,1 24c.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: Zq 0 u,pi L 4!6 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