GW1--05209_Well Construction - GW1_20230814

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
^t C- CCO - - ' 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
-I 7 76 ft. fro ft. a 6-Pill
/
d 7, ft. k-76-ft. fs- &p 11,1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Water Wizards Inc FROM TO DIAMETER THICKNESS I MATERIAL
0 ft. '3 ft. / fai in. s1R a i pvc
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
!^� /��(
2.Well Construction Permit#: I'f (3 c�" V C1 FROM , TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,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) E-esidential 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: v ft. (0 3 ft. 3k I-6kl�°I Pc ec a- I j.a.,.- i n
Monitoring DRecovery ft. ft. Plekce 7c6 lbs
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO - MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) 0 Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) flOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size,etc.)
O ft. G ft. IRe,cj c G y
l
4.Date Well(s)Completed: 61;?51 3 Well ID# G ft. 5-6--- ft. nld
5a.Well Location: 55" ft. I e6 O ft. &fl®..y i2v�O(-.
YA T P-S Non-,-s ft. ft. u �^ .
�( -.
Facility/Owner Name Facility ID#(if applicable) ft. ft. ri,
..,*L i� -�V k-.Lo•
1 alo2 �Or1Cs ls.S4er Rd RA
Ore l�•l� ft. ft. I\ J
IG 1 L. 7)71
Physical
Address,City,and Zip c Q 7S"23 ft. ft.
{ l-'�I"CO►'� 135 - VS' 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36. 9IT-1641 N - 7` 40I5-'a'll W
, ..., , -- -iC:9 (----- ZIS 77 d ep-. 5--d 3
6.Is(are)the well(s)1erntanent or 'Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or 10 with ISA 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: - I f O - , (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 a 200'and 2@100) construction to the following:
10.Static water level below top of casing: i- (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: tvv ll cam? (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: Air- 2U-6,-y- 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) ICJ Method of test:&CJ1.:an 020 r11i/) 24c.For Water Supply&Injechon 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: H I4 t' Amount: S. C a 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