GW1--05268_Well Construction - GW1_20230814

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.We Al Contractor Information:
'rJAI*Ji--ems C-6 — 14.WATER ZONES
FROM TO DESCRIPTION '
Well
`Contractor Name
C["I /7'C ft. �ft /aisanGYI
ft. ft..
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Water Wizards Inc FROM TO DIAMETER THICKNESS��r I MATTElRIAL
0 ft. �fl// ft. in. `�GV� I Pt _c_
Company Name 166 INNER CASINGOR TUBING(geothermal closed-loop)
2.Well Construction Permit#: L.4 3...5 119 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.SC
Water Supply Well: FROM REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 0 ft• ft. in.
[3Geotherma1(Heating/Cooling Supply) Ill Re -ntial Water Supply(single) ft. ft. in.
0Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
nlrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0
ft. I -e ft. x-4- p�i,_a /d Cbs
Monitoring ecovery ft. t/ ft. G" C>
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0i Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 19.SAND/GRAVEL PACK(if applicable)
'Other(explain under#21 Remarks) FROM
ft. TO DESCRIPTION(color,hardness,solUrock type,grain size,etc.)
! ft.
4.Date Well(s)Completed: 67 jWell ID# ft. ft.
5a.Well Location: ft. ft. t~i,ia.!ter�1.,.i 1V C- _?
/1r� r
kq 9 1�z ft. ft. AUG ,.. ZU .l
r-1 Y �1n
Faccility/O er Name //Facility ID#(if applicable)e) ft. ft.
60-0( 'W. l/'r e—uv Tr( Ob-e�o_wt g2-) ft. ft. trr:L, ti..#r� ?r::a;:�:� Ur.Ii
Physical Address,City and Zi
ft. ft. M(;1=� 'o- Lv
21.REMARKS
County C it Parcel Identification No.(PIN) c ' c'®
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: C//���,03 eA
(if welllp field,one lat/lon-g is sufficient)
/' �j/� 22..�jCeertti`fiic�at�ion:
)C,,0Wr/`L : N--27,gKO`J`L -6 W Y// 6l/ i 4--/3//ca3
6.Is(are)the well(s)NI;'•rmanent or OTemporary 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: es or QNo with ISA 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: Q'�✓ (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: It (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: G`'ct (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: 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) I g Method of test: t0 / 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
13b.Disinfection type: Amount: 1 �(JL '3 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 2-22-20fc, ,