GW1--03959_Well Construction - GW1_20230612

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
John Often 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3024-A 70 ft. Up ct. 3 6PLA
NC Well Contractor Certification Number 0999W t-190 ft. 6 I p M
y 15.OUTER CASING(for multi-eased wells OR LINER if a Gcable
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
® ft. / ft. I in. S®Q�I PVC
Company Name l0
1 1 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: � l 1 0� —T l FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i e.UIC,County,State,Variance,etc.) ft. l O ft. in. SCH yQ
3.Well Use(check well use); ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) FR esidential Water Supply(single) ft. ft. in.
lndustriaL/Commercial Residential Water Supply(shared) 18.GROUT
ltrl ation FROM I TO M TERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 3 ft. ,b;.
Monitoring I Recovery 0 ft. f)® ft.
Injection Well: L�
Aquifer Recharge QGroundwater Remediation
_ 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology IDSubsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,solYock type,grain srae,etc.
b ". 3 ft. vet-b
4.Date Well(s)Completed: Well 1D# 3
ft. 112 ft
So.Well Location: ft. ft. ;, . L
baoc p IC�>ti�s ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. : r i'_ -,
rJ e^' C k ft. ft.
Physical Address,City,and Zip 7 ft. ft. UIY .Lr
f`etAil
21.REMARKS s;., ;_
��.
County �- Parcel Identification No.(PIN) � a
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) Q 22.Certification: l C W4
6.Is(are)the wells) . Permanent or Temporary gnature of Ce ed Well Contractor 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: OYes 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5 oZC� (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: & the (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: R.0-6'—✓ 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: gt0aioti 20 WA 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: 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