GW1--05202_Well Construction - GW1_20230814

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.W7(1 Contractor Info�4
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name C(.( 2ft. /CR ft. c
tC/ ¢7eki
r
Cft. ft. 6
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
6 ft. c ft. (-1/ in.in. b /Cio
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) 4-
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: 1F7R fiOn REE TO
0 ft.
DIAMETER SLOT SIZE THICKNESS MATERIAL
"-Agricultural IQMunicipal/Public ft. in.
Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FRO TO MATERIAL EMPLACEMENT OD&AMOUNT
Non-Water Supply Well: [t. G� ft. � Q�� „t 1 f S-
Monitoring 'ecovery ft. ft. L �+ `C-
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
! Aquifer Test IStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(rotor.hardness solUroek type,grain size,etc.)
'�¢, I r r I y� ft. ft.
4.Date Well(s)Completed:`'l/�I/d 1 Well ID# `i I `1 r 1 ft. ft Y.. _T.(ten 1 K'
ft. ft. 4 Aw....d.,P k.-t Yr r
5a.Well Location:
per. ft. ft. Aur 1 4. 2023
Facility/Owner
ility/Owner�Naame� Facility ID#(if applicable) ft. ft.
Pi
D %V�[r' If I� L/�C/ l/mi ` (/ 74‘- ft. ft. Ir:.vrrr^.PAA 1 .^: , ::;� Unit
Physical Address,City,and Zip ft. ft.
fr,faciA
21.REMARKS //'' � /� _ /��Cy Parcel Identification No.(PIN) `�l,-1, l oT�r -jam l l
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - ?�
13
(if well field,one llaat//llong issssufficient) �7 /� Q� 22./Certification: (,//� j /q 7
C 9-`7 f ti.�'l N ` !6•"!- J i� - W 19(/] _ � '� � l/oL-1.!oL")
6.Is(are)the well(s) neat or Temporary Signature of Certified 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: Die or DNo 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(jW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I('� SUBIVIITI'AL INSTRUCTIONS
9.Total well depth below land surface: `"-t. a (ft.)
p 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: .0,6" (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: V� (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:e'vA� . 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: f `r t3'` Amount: j�r ."-'< completion of well construction to the county health department of the county
• where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016