GW1--05205_Well Construction - GW1_20230814

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
tI IL SP1 • SC5� 14.WATER ZONES
We 1 Co/nnttactorrName FROM ft. TO DESCRIPTION
O
,� ( b � � s elPrh
NC Well Contractorr/�/ Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL PVC-,
,¢ .
d ft. 4,s ft. (/ in. SC!•1 VNr
Company Name 1 �" ,`5�r
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.
17.SCREEN
Water SulSupply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 0 ft• ft. in.
Geothermal(Heating/Cooling Supply) residential 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: ,e, ft' (OS ft• NEAT P j lop I 135
Monitoring DRecovery ft. ft.
Injection Well: tt. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IDStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soiVrvck type,pain size,etc.)
pp//
ft. ft.
4.Date Well(s)Completed: 1 _421 —a3 S��I Velt ID# I 6. L'I 0 ft. ft.
CI Sa.Well Location: ft. ft. t L.�LP i '�,/F
gpJ 0 -4 MbL.EiL ft. ft. Q1II' 1 4. L.Facility/Owner Name j� Facility ID+#(if applicable) ft. ft.ft. ft. irlF�"t""Jvil ;'r,^_•�u=`'z?,-2 i.iR/
Physical Address,City,and Zip ft. ft.
21.REMARKS
County Parcel Identification No.(PIN) (Z ft E u E Q It D9
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .
(if well field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s){ermanent 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: 121Yes or ONo with 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill our 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: (� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /p (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@200'and 2@I00') construction to the following:
10.Static water level below top of casing: OAS' (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. t.) I/14 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: P.d n�q above, also submit one copy of this form within 30 days of completion of well
r t I 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: �� P 24c.For Water Supply&Injection Wells: In addition to sending the form to
1T the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: I4 1 4 Amount: I I Z 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