GW1--05204_Well Construction - GW1_20230814

limmonmomirro
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.We CContractor Information: _ ^
Il�‘(^ 1 — 14.WATER ZONES
Well
sContractor Name
/r /�
FROM TO DESCRIPTION
i/.:,r ft. ft. 1
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
0 ft. if-01 ft. 4 in. 3 i , p
Company Name ✓C {I
16.INNER CASING OR TUBING(geothermal closed-loop)
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 OMunicipal/Public 0 ft• ft. in.
Geothermal(Heating/Cooling Supply) DR.gsrdential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: [/ ft. qo ft. D -!_�1, ? / �jcoI
Monitoring ecovery ft. ft. ( r�C 61 / u
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 0IStormwater Drainage ft. ft.
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
FRGeothermal(Heating/Cooling Return) ( Other(explain under#21 Remarks)
oM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
ft. ft.
r ^—r--'.t-.
4.Date Well(s)Completed: (J/A//, Well ID# eQ 10,'? ft. ft. r ti`L,,,,Le L.:; f -
5a.Well Location: ft. ft. ��G 1
V' n/�(,frj,c- ft. ft.
k� 1- �Il
ft. ft. lnMrrF.:.t�71 ran'•;-r xit LR
Facility/Owner�n/ Name f J �, Facility ID#(if applicable) �� �
Lez 31 ey—orC'Di.v�'��. � - GJ`z 7 ft. ft. C}ra t�:�^:r
Physical Address,City,and Zip ft. ft.
���� r„ 21.REMARKS
Co ty V 1 Parcel Identification No.(PIN) � �(� L�Y'c` �� to
7
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: f ` '
(ifA ell field,one lat/long is sufficient) _ 22.Certification:
IVY
6.Is(are)the well(s) nent or DTemporary
Signature of Certified Well Contractor Date 3
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: es or DNo with 15A NCAC 02C.0100 or ISA 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: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: G} Pi" (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@2200'and 2@100') construction to the following:
10.Static water level below top of casing: o�;1 (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: G Cq (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: a"' ( 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) to Method of test oniyiT 24c.For Water Supply&Injection Wells: In addition to sending the form to
1I' —I�jthe address(es) above, also submit one copy of this form within 30 days of
I13b.Disinfection type: 4 J Amount: rtis--< 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