GW1--05289_Well Construction - GW1_20230814

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
JSE1I���/ ` i
Cs ��. .� i 14.WATER ZONES
Well Contractor Name FROM to‘
DEDESCRIPTIONLiti-i; -C it0 ft. tota ft. la8
e14„
ft. 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. �U ft. 4 in. e vt 2 pt/i-C
i-
Company Name f1' K a�b V' 4 (�
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 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.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural IDMunicipal/Public A ft• ft. in.
Geothermal(Heating/Cooling Supply) • esidential Water Supply(single) I. ft. in.
Industrial/Commercial DIResidential Water Supply(shared) 18.GROUT .
Irrigation FROM TO MATERIAL EMPLACEME/ 7c443
THOD&AMOUNT
Non-Water Supply Well: 0 ft. CO ft. n A l tt_rs�-v. (�� �
Monitoringft. ft. 0
Injection Well:
ft. ft.
Aquifer Recharge EjGroundwater Remediation
19.SAND/GRAVEL PACK(If applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. ft.
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) 0 Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soli/rock type,grain size,etc.)
Geothermal(Heating/Cooling Rettu'rn) a
I/lU Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: ��. Wel1ID# ft. ft.
ft. ft. �^ "'" r
5a.Well Location: < r '7
- -^
ft. It. '�- <-v .,...a is 1.4.
1/1/64 40 ft. ft. A U 6 1 _• 2023
Facility/Owner Name Facility ID#(if applicable)�Ali�
G/2" / ii /,Iv v 2 7ra ft. ft. WTI rir,,,,n4iPn
Physical Addresfity,and Zip ft. ft. p;51Qi iO J
OkC_J21.REM�ARQKS� ./ I ��{County c1 Q &rQ n ✓I I I( Parcel Identification No.(PIN) n_t° ` / I "'Ze r t a""
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: CI-9°
(ifif well field,onec 1stt/lo/ngg is sufficient)- �i / 22.Certification:
`r ' (J 1.44 � N -'7`c , q&Z 6-( W ig,-14,7 .::.1.(1e,,e 6-7/67Q2
6.Is(are)the well(s)!i' manent or [ITemporary 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: Yes or EjNo 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: 00 (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: a< (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: t (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
yy����,,� above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: CJ 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) 6 Q Method of test:6 kt,i411� pply 24c.For Water Su &Infection Wells: In addition to sending the form to
1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: / 4 fd- Amount: 6 ot,e" 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