GW1--05207_Well Construction - GW1_20230814

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Contractor Information:
4
Eric Cook 14.WATER ZONES
FROM TO DESCRIPTION•
Well Contactor Name
4577-A B a-)ft. 0.5 ft. a Cam.PM
cu.-ft. 61t. 44 6.91M
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
f
D ft.
Company Name 6 '3 L CO 1IA( in. SD a, Pic
OSWP-000180-2023 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 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 R1A7'F.RIAI.
Agricultural DMunicipal/Public ft. it. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
r Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft. 60 3 ft. /f Finn Pow-ea ti' Hyc &lo o l Q{Gt.P
Monitoring DRecovery ft. ft. .700110S
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IjStormwater Drainage ft. ft.
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets ifnecessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,horde s,soWrocktype grata she etc.)
C) D. 3 it over btc n
4.Date Well(s)Completed: 7" 723 well m#A85/232 3 ft. LP ft. g Cf y
5a.Well Location: 47 ft. ,A649 ft' 6(e QQG k.
Yates Homes f` f`
Facility/Owner Name FacilityID# ifs licable ft ft. (a.o i;gsg',a F'Vt-
400 Welch-Whitfield Rd Timberlake NC 27583 ft ft.
ft. ft. AUG 1 i, 2013
Physical Address,City,and Zip
Person 21.REMARKS
County Parcel Identification No.(PIN) DWQ.:20:3
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 7 22.Certification:� /�
3(0t3) 79 S 7S'� N , 75'1 3o w . -- 9s77 11 '7-19
-a3
6.Is(are)the wells) 'ermanent or DITemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certfty that the xr1/(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or Et< with 1 SA NCAC 02C.0100 or ISA NCAC 02C.0200 IVell Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature ofthe 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 I 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: 02400 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: t: 6._ (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1
11.Borehole diameter: 62 si (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: f T
A I, 2.00E ct/ above,also submit one copy of this form within 30 days of completion of well
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) IO Method of test:all7Wel at) MiA 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
1313.Disinfection type: WIN Amount: IA OZ_. completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016