GW1--05211_Well Construction - GW1_20230814

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 6--.....T
1. l Contractor Information:
I AY C„„4V G 14.WATER ZONES
ft
Well Contractor NameLi iicr FROM TO DESCRIPTION
l `4 ft. 0 . a3f7iyl,
�iiJ 1J �j ft. 7 ft. (,
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. 611 ft. (,,.f �],Q(,�in. sD
Company Name 11 �^ ` t'c
(�
_etas^o `iI a 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 1�,(� � 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: FF7R SC REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
®Agricultural Muni 'pal/Public 0 ft• ft. in.
Geothermal(Heating/Cooling Supply) DKidential Water Supply(single) ft. ft. in.
III Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
' Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: /) ft. /'D ft. Rid d is Rv. e I co Ms
111 Monitoring 'ecovery �// ft. CD ft. f�1 c {`�""'- I
Injection Well:
ft. ft.
•Aquifer Recharge ['Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
•Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
I Aquifer Test IDStormwater Drainage ft. ft.
•Experimental Technology ljSubsidence Control ft. ft.
•Geothermal(Closed Loop) ['Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/roek type,grain size,eta)
111 Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: C49.47, Well ID# ft. ft.
5a.Well Location: ft. ft. -
'lyva., ft. ft. F �.'r/b-� t'.a lrsae.
1.
Facility/Owner Name Facility ID#(if applicable) ft. ft. A U U 1 ', 2023
gag te-411 1 Qn th!!s 6041 ILL-OL/7 ft. ft.
Physical Address,City,and Zip ft. ft. ❑O 3 :.7
21.REMARKS n�f ,,p� �� ��l
County Parcel Identification No.(PIN) 1v` t)Ve - I-���l-"�+ '•7 C%Z/e AA
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
/C.19'jcukY . N -7R.0 elti WI W C. G�:2ki/�.�
6.Is(are)the well(s) nent or Temporary ature 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: 5 or DNo . with 15A NCAC 02C.0100 or 15A 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: J Q F'1" (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@100) construction to the following:
10.Static water level below top of casing: tQ 6- (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+ ir�/ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. G r l (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
_/y above, also submit one copy of this form within 30 days of completion of well
12.Well construction method 415 J 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) (Q Method of test (4,1119 24c.For Water Supply&Injection 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:14 4- 14 Amount: 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