GW1--03956_Well Construction - GW1_20230612

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
✓�t-yl k 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a livable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
P) ft. ft. in.
Company Name r�
f_ /� `�a ry fj 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Constriction Permit/I: �S Lg ` f/o0 /5 ,2— 2 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) � ft. /s�V10 ft. in• w
3.Well Use(check well use): ft. [t. in.
Water Supply Well: 17.SCREEN
�^-� FROM TO DIAMETER SLOT SIZE TMCKNESS MATERIAL
1_
Agricultural _I nicipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) ' esidential Water Supply(single)
:]Industrial/commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: tt. L., els
Monitoring Recovery ��
n Well:Injectio G
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Coolin Return) FROM TO DESCRIPTION color,hardness,sotumck type, in size,etc.)
( g/ g ) Other(explain under#21 Remarks) ft. ,� ft.
4.Date Well(s)Completed: —` ^2__3 Well ID# 7 ft. ft.
Sa.Well Location: ( ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
4+r I/ i >r �' ! ft. ft. ilk d 2023
I lePhy�al Address,City,and Zip ft. ft. .ir• :_. ;_ i t ..
21.REMARKS n :n •�
�' S Din
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:
3&, LYM37I N 7$r��,23 / w
6.Is(are)the weIl(s)Qfejr.1nent or QlTemporary Signatu of Certified Wel Contrac or 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: QYes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Nell 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: A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 a(�l 00'and 2@100) construction to the following:
10.Static water level below top of casing: zx�' (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: CO!% (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: �ta �'� 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) 76 Method of test: D.-Jn;W' For Water Supply&Iniection Wells: In addition to sending the form to
-fie address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: /�62 Lam*'+a _5 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