GW1--06871_Well Construction - GW1_20231030

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. WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well ContractoryyInformation:
11el O'Neftt .
'14.WATER ZONES t i
FROM TO DESCRIPTION
Well Contractor Name it. �/3 ft.
. __S-/CPfil ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Wizards Inc FROM TTOO DIAMETER THICKNESS MATERIAL
,MA�/TEERIIAL
Company Name 0 n / / "'T " 1` ' . .
c�r� �y 16.INNER CASING OR TUBING thermal closed-loop)
2.Well Construction Permit#: 3(�10Y/ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): - ft ft. 1n
17.SCREEN
I Water Supply Well:
11
FROM TO DIAMETER: SLOT SIZE THICKNESS MATERIAL
Agricultural cipal/Public ft.
it.
it, la.i,
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. in',.
Industrial/Commercial DResidential Water Supply(shared)
IS.GROUT
.Irrigation FROM TO MATERIAL EMPLA OD&AMOUNT
Non-Water Supply Well: 0ft- ft- I Q
Monitoring I�Recovery ft. �� ft / �% �,� ✓ �r
�co/4
rvet
Injection Well: ft ft. S.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IoStomiwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. - ft. I
jGeothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,sollrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) n Other(explain under#21 Remarks) IIP�l�$�C�
4.Date Wel(s)Completed:9' ?-2-3 Well ID# 7 f- b k' ft „�/9e(r,/,_
5a.WellLocation: G,g Z¢QO`t. ^ (0 ,4 ' ,: - ,
Charles Hobgood fr ' t, -',a 47.: 1 1 1
�f
Facility/Owner Name Facility ID#(if applicable) ft ft'
1072 Dr Finch Rd Henderson NC 27537 ft. n• 0 C T 3 0 2023
Physicalandft. f4 Inivin. ;f^il ?,,..._,- •
Ire City, Zip �y y �y ....a,.,,nn i tau
Vance Q�t7c O!6 / 1 21.REMARKS i-%';v i;. '!:d;
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
, ,..14176,33 N — 7g..a&7 ix w 7_ . Za�3
6.Is(are)the well(s)jrmanent or Temporary igrca /Winedwe Co for q Date
�� By signing this form.I hereby cernfy that'the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: D Gar‘Yes or 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 021 remarks section or on the back of this form.
23.Site diagram or additional well details:
• B._or.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
:F
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: - • �ijy 00 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths_jfdifjerent(example-3@200'and 2Q100') construction to the following:
10.Static water level below top of casing: 7c (ft) Division of Water Resource's,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
IL Borehole diameter: lV 1f9• (fn.) 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: at3 .t / construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WF.i.i S ONLY:' 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test �10itt/' 2447,,,,,24c.For Water Supply&Infection(Wells: In addition to sending the form to
the address(es) above, also submit one;copy of this form within 30 days of
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13b.Disinfection type: , /1/ 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