GW1--06911_Well Construction - GW1_20231030

Print Form V r
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1
1. Il Contractor Information: f
., �s 14.WATER ZONES I '
Well Contractor Name FROM TO DESCRWI1ON
�-l�h c, I'q�ft. I efdam-: , fde )wl
ft ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap llcable)
Water Wizards Inc FROM TO DIAMETER; THICKNESS MATERIAL
Company Name 0 n 15 V D. Li 1 iii' ao Pvc,
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. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS _ MATERIAL
Agricultural DMtmicipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) Bidential Water Supply(single) R. ft in..
Industrial/Commercial OResidential Water Supply(shared)
18.GROUT
I Irrigation FROM TO MATERIAL EMPLACEMENT OD&AMOUNT
Non-Water Supply Well: 0 ft c‘O ft. Pard1-_• J PO /VO IQ 5
Monitoring ecovery R. ft '""TJ i
Injection Well:
• ft. ft.
Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(If applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test jStormwater Drainage ft ft. 1
erimental Technology OSubsidence Control ft. ft
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness solllroek type,grain sGg etc.)
,1 'f, () ft. ft.
4.Date Well(s)Completed: w/✓ 423 Well ID#A65/153 it. H.
5a.Well Location: ft ft , ^^
Nell Smith ft. ft.
+�-'k •�: , ;a>', �"`a
Facility/Owner Name Facility ID#(if applicable) ft. ft
543 Hillsborough Rd Timberlake NC 27583 ff. ft 1 D T 2023
Physical Address,City,and Zip ft ft 1 In vrer ri;;^n Pro,^,.;2; )iS1.1{
Person 21.REMARKS U.'` i 'e•,?,Zty
County Parcel Identification No.(PIN) 1� I 1 I:ABC 4(J r
ddegrees/minutes/seconds or decimal d ees: .in e..0-�. tt
Sb.Latitude and longitude indegrees:
1.
(if well field,one lat/long is sufficient) 22.Certification:
SG,, l'yJ 2 N 7iC61I6'36 d w 04,..., Co73/a6.Is(are)the well(s)rig ' .,:neat or Temporary St ngnattuxeofCertrfied 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: I111p or ONo 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 wider#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 tolprovide additional well site details or well
construction,only 1 or is needed. Indicate TOTAL NUMBER of wells construction details.Yon may also attach additional pages if nenossary.
drilled: SUBMITTAL INSTRUCTIONS j
9.Total well depth below land surface: ,CO O" (ft-) 24a. For All Wells: Submit this foim within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(d1200'and
2@100') construction to the following:
10.Static water level below top of casing: pC,4. (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: r'I l (in) 24b.For Infection Wells: In additi i to sending the form to the address in 24a
t __ i _ R' above,also submit one copy of this form within 30 days of completion of well
o
12.Well construction method: )L..e.)�W - construction to the following:
(Le.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
J� i .
13a.Yield(gpm) 10 Method of test \ 24c.For Water Supply&Infection Wells: In addition to sending the form to
u ii ' I' ,, p� the address(es) above, also submit one,copy of this form within 30 days of
13b.Disinfection type: r1 T CT Amount T/ 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 I Revised 2-22-2016
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