GW1--05203_Well Construction - GW1_20230814

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:: J
�GJ"�/"t IT%rCi - —..- -- - 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name )
4"6��' G /L j 1, ft. I(r2( ft. �j l Vl
(�l� ft. ft. R
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Wizards Inc ' FR M TO DIAMETER THICKNESS MATERIAL
ft. ltr ft. ( / in. 5 at n n 4 t/G
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
C3 C
2.Well Construction Permit#: FR•, TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) i A tile ft. �j! in. r �f ��
3.Well Use(check well use): ft. u� ft. �J} in l�'�� ]��lJ�
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public 0 ft• ft. in.
OGeothermal(Heating/Cooling Supply) laIgidential Water Supply(single) ft. ft. in.
Dlndustrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 10 ft. i. ei et• [ ctG1-( I.A Q /40145,
Monitoring covery lj ft. ft. li-a 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 0Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROMft. TOft. DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
�/A/093 US I I`40 ft. ft.
4.Date Well(s)Completed: Well ID#
Sa.Well Location: ft. ft. F.. %.:..C V_,`t°"
/tl✓1 y IJ�!►�1r!,Q-� ft. ft. a w
Facility/Owner Name{ L - ` (� n Facility D/I(if applicable) ^��/� ft. ft. A U tj 1 : Z i)23
r11i p iiivt/ . f'K, T 743- 94.4.. f6s6 ft. ft.
,.�,,i..� 7rr. .9! .FA Lift
lrt ^-�'
Physical Address,City,and Zip ft. ft. li�`i �
8,,.�� 21.`REMARKS
� / /
County ��� Parcel Identification No.(PIN) -✓��1-0-4 ( — c ` 1
11471
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: C r "3
(if well/field,one lat/lo�ngg�is sufficient) am' 22.Certification: ,�Q��,� t�
)6 i 5 a-Ci -01 N "7*,/I a�i�,gt fci W ; Cal 4 i L(1' (/
6.Is(are)the well(s) 4 P nent 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: [or ONo with I SA 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 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: L 1v (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: 0'6 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use'l 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: U 41. (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 Censer,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
13b.Disinfection type: f 0 T4 Amount: b, -0W 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