GW1--03952_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
ct
J 71 J 7 ft. Kft. i 6— f'.\
ft ft. 16 Is tt. fv\
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable)
Water Wizards Inc M TO DIAMETER THICKNESS M ERIAL
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 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 I_ eesid,
ipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) ntial Water Supply(single) tt. tt. in
Industrial/Commercial Residential Water Supply(shared) 10.GROUT
Irrl ation FROM TO MATE IAL EMPLACE ME METHOD&AMOUNT
Non-Water Supply Well: ft. ft. �i
Monitoring DRecovery ft. ft.
Injection Well:
ft. [t.
Aquifer Recharge DGroundwater Remediation
__ 19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery [Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [StormwaterDrainage
Experimental Technology [Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets it necessary)
Geothermal(Heating/Cooling Return) nOther explain under#21 Remarks) FROM ft. ft. TI To DESCRIPTION(color,haran soiltrock type,grain sia,etc.
2
4.Date Well(s)Completed: 5-dam Well ID# ft. ft.
Sa.Well Location: ft. tt. ti`Z, ,,E„e Lw 9 l® (_.
Degnfs MCD6V,+� ft. tt. _11-11N] 1 2 2071
Facility/Owner Name Facility ID#(if applicable)
annul. L r, S&A- o t-Ih, n(i a.73 Lf3 ft. ft.
C
t 3
Physical Address,City,and Zip ft. ft.
Parso ^ ( [' 21.REM KS
County J ✓ Parcel Identification No.(PIN) oraj
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: f /Y
(if well field,one latflo�ng is sufficient) / (�/ 22.Certification: / /J 12
36 -`� ~
70 N 7% t 140 6S W ✓ � 41S
6.Is(are)the well(s) Permanent or [Temporary Si tore of Certified Well Contractor Date
By signing this form,I hereby certify 1 the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: es or No 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: 1 r SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I�1� (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@100D 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: ll (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
I� n'/ above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1 ��J Y 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: J M 24c.For Water Suably&Iniection Wells: In addition to sending the form to
MM ! the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: V U4,(r 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