GW1--03969_Well Construction - GW1_20230612

PHrit Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Water Wizards 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
Taylor Often
m
NC Well Contractor Certification Number 16.OUTER CASING for multi-ca ells OR LINER(1faPRIicable
4497-C FROM I TO DIAMETER THICKNESS MATERIAL
tt �, i V a
Company Name 16.INNER CA G OR TUBIN eothcrmai c osed-loo
2.Well Construction Permit A FROM TO I DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i e.UIC,County,State,Variance,etc.) R ft. In 11 Y Y i
3.Well Use(check well use): it. R' in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft. ft. In.
Geothermal"(Heating/Cooling Supply) PfResidential Water Supply(single) ft. ft. in.
�IndustriaUCommercial QResidential Water Supply(shared) 18.GROUT
Lrrigation FROM I TO MATERIAL EMP CEMENT ETHOD&AMOUNT
-y
Non-Water supply Well: ft. U [ R v 1441- � Z!z''
Monitoring Recovery ft ft
Injection Well: ft ft
Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)_
Aquifer Storage and Recovery }Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage M n'
Experimental Technology IQSubsidence Control ft. ft
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if nec
Geothermal FROM TO DESCRIPTION color,hardness,wlllr k s etc.
(Heating/Cooling Return) 'Other(explain under#21 Remarks)
4.Date Well(s)Completed: �-23 Well ID# 0 01. ' `yam vi--
So.Well Location: f. ft v`
Cya:%CA f1L ft
Facility/Owner NarneJ Facility 0"
_�(ifapplicable)
`
Physical Address,City,and Zip 0' R
�ca►'ty 1 u, 2L REMARKS
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-
6� � N am'7 Y
�L 5 W •--
6.Is(are)the well(s) Permanent or OTernporary Signature of Certific ell ontmctor Date
By signing this m,I ereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: An
or DNo with ISA NCA 02 .0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,tdl out 17town well constr, formation and erplain the nature of the copy of this re cor 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-I 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: (R•) 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
— A above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: ��yt�V 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: 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
f
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