GW1--05206_Well Construction - GW1_20230814

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
N7tei/4 ®)/ "' ' 14.WATER ZONES
TO FROM
Well Contractor Name DESCRIPTION
��ft. 90 ft yc o0,
30�.�/�t� ft. B.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LiNER(if ap likable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0ft 63 ft. /#2, In t,e•el A/C-
Company
/�
16.INNER CASING OR TUBING(geothermal closed400p)
2.Well Construction Permit#: 05 n(4)p- (/007,3 %(�-2be3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le_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 DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) jesidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&A OUNT
Non-Water Supply Well: 0 " 6�/t fL A''i4 o La{qpo Ad
Monitoring IDRecovery ft. ft. / J
Injection Well:
ft. ft.
Aquifer Recharge D Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater 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 ro�9 DESCRIPTION(color,hardness,sowrocktype pram etze etc.)
4.Date Well(s)Completed: 7'2 7 Z$weu ID#A73/260 7 ft 46 ft .set- /-/_/al
5a.Well Location: T P ft' 7 D ft Cnr ^ ` '��f
St
Conrad Shade! ft. ft. y( _
ft. ft. F' S w.,'t r"-
Facility/Owner Name Facility ID#(if applicable) t,,,P L. a `!° �,v„
148 Copper Shell Lane Timberlake NC 27583 ft. ft AUG 1 23
Physical Address,City,and Zip ft. ft u t J
Person 21.REMARKS rose- :;^1 P!rr.vo!.5:.-2 Uni
110(4
County Parcel Identification No.(PiN) (;W .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Ce ti
t3lo 3 Ll&1 N -7A. 42� w ,�� 3o2-Q4p 7 27. 2�
6.Is(are)the well(s) ermanent or Temporary Signs of Certified Well C r 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: DYes or IRK with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 IVell 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2 2 L ) (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dtfirerent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: 2-5- (ft.) Division of Water Resources,Information Processing Unit,
ifwater level is above casing use"+" ` 1617 Mau Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: Li"?S (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: Osices construction to the following:
(Le.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) 414 Method of test:Skan 2 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: If 7/1 Amount: q C>t.40/5 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