GW1--03994_Well Construction - GW1_20230612

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
U 14.WATER ZONES
Well Contractor
Name FROM TO DESCRIPTION
(r M
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased ells)OR LINER if a Iicable
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
ft, ft. in. [/i PV(
Company Name 16.INNER CASING OR TUBING eothermat closed-loop) v
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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural eesidential
ipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) Water Supply(single) ft. ft. in.
IndustriaUCommercial DResidential Water Supply(shared) 18.GROUT
Irrl ation FROM I TO MATERIAL EMPLACEM METHOD&AMOUNT
Non-Water Supply Well: ft. ft. Id 1 a rr ,
Monitoring L Recovery
Injection Well:
et. ft.
Aquifer Recharge [)Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery [)Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology [)Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) FlOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sotvmck type,grain size,etc.)
r ft. ft.
4.Date Well(s)Completed: "W J Well ID# ft. ft. i�'� ,-4_f _1 �.�I V
5a.yWell Location:
W 6 {S ft. ft. J�HN i r'
Facility/dkvner Name Facility ID#(if applicable) ft. ft. lntof a.i Pis^7C 3i�' VA
99 alc1,al yld�i ft. ft.
Physical Address,City,and Zip
Cas U V e 21.REMARKS
County Parcel Identification No.(PIN) U I r l z 1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: A�tm
1 n t
(if welfield,one f attlong is sufficient) O 22.Certification:
�d� N �� �� r S 7 W ✓ ���,,6 ,,�
6.Is(are)the well(s) ermanent or [)Temporary Signat&akf Certified Well Contractor Date
By signing this form,I hereby certify that well(s)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 I 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: [ V) (B•) 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: �� (in.) 24b.For Injection 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: 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: M 24c.For Water Supply&Injection Wells: In addition to sending the form to
L (�� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: T Amount: v UA(&i 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