GW1--05198_Well Construction - GW1_20230814

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
._3� -- - -- - FROMATER ZONES TO DESCRIPTION - - _ -Well Contractor Name
14 9. ^ft. s i tuft. £4.p0
32�'�p !/IOff ft. lill�ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. /_ )ft. b 4 in. c5 c-a - i p
A wr) 37I 4 ' 16.INNER CASING OR TUBIA (geothermal closed-loop)
2.Well Construction Permit#: � FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State, ariance,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 OMu 'cipal/Public 0 ft• ft. in.
Geothermal(Heating/Cooling Supply) IT esidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEME METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ea) ft. 3) I'f0/G p/A43 DvIYel
Monitoring Recovery ft. ft. !� 600)105
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. ft.
Experimental Technology E3Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) DOther(explain under 421 Remarks)
oft. -7 ft. Q veal? can
TO DESCRIPTION(color, ness,solUrock type,grain size,etc.)�.- .
4.Date Well(s)Completed: 5'2. '23 Well ID# ' ft. C, ft. ej
5a.Well Location: 5/ ft. 3"o ft. few..J4
adi, ec O'LYh D ft. ft. -. 7 a•. .,.�r
Facility/Owner Name Facility ID#(if applicable)) ft. ft. i\ QdP�-j`�y ;{ O
ft. ft.
Physical Address, �(- ft. ft. AUG 1 ` 2023
✓ Z?S3?
21.REMARKS Ire:- , :E;;n '' 2p.:7,4 g ` nA
C.r,u- O_�3� 0 -OO�e DWaWQ C)G
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one� yL9 latQ/long is sufficient) � 22.Ce 'Ica f n: �I /�
3 . /53 N -7$. ys,[�0 4 W // ® ? 2.y., 5�9 -23
6.Is(are)the well(s)1111!'.'ermanent or DTemporary igna of Certified Well Con etor Date
� By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
DY
es Is this a repair to an existing well: Yes or o 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: 2 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 300 (f•) 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 4)100) construction to the following:
10.Static water level below top of casing: -2.4' (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: &wi (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Q above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: ft0 � 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) N Method of test:tflkkai � 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: 14 /fri Amount: ar elluo a df , 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