GW1--06930_Well Construction - GW1_20231027

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'WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: _ __ `•,-,• •,1'
1.We Contractor Information:
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14.WATER ZONES i - *,•,- "`�
Well Contractor Name �FIjDM TO��ft DESCRIPTION '•
ito:cfp wt.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Wizards Inc FROM r �� DIAMETER In. THICKN;SS MA
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Company Name97
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16.INNER CASING OR TUBING(geothermal closed-loop) .
2.Well Construction Permit#: v =Q3- 31.1 FROM TO D Tmc uss MATERIAL
List oil applicable well construction permits(Le.WC,County,State,!Variance,etc) a ft. C 3-a ft. m. 51111127.
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3.Well Use(check well use): ft l ft. in. .
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural DM cipat Public ft. rt. In.
QGeothennal(Heating/Cooling Supply) fej esidential Water Supply(single) fL ft in. •
tjlndustrial/Commercial DResidential Water Supply(shared) 18.GROUT -
nkripation FROM TO ' MATE I I EMPLACEMENT OD&AMOUNT
Non-Water Supply Well: 0 ft.
4 Aso f I%;`1/A.Alt e/- //-c Qal,�.(
I�Monitoring jRecovery ft. • ft. I 1t
Injection Well:
ft ft•
NI Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK[d applicable)
I li Aquifer Storage and Recovery @Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
I Aquifer Test 0Stormwater Drainage ft ft.
®Experimental Technology jSubsidence Control :ft, ft i
I r
R Geothermal(Closed Loop) OTracer '-20.DRILLING LOG(attach additional sheets if necessary)
(Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/reek type,grain size,etc.)
I ft !t i
4.Date Well(s)Completed: 1 t2- -�J7 Well ID# fr. ft j
5a.Well Location: / ft R i
UWre fio Q Os��ows�M ft. ft j :
Facility/Owner Name Facility ID#(if applicable) ft. ft. "' ••.i i,' u
di0 i Sehl-e9 la guvi le ifV1 s ix,aistr i ft. ft. OC T 2 7 2023
Physical Address,City,and ZipOkr ft. ft. ! �-'
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in alp 21.RE
County t l Parcel Identification No.(PIN) •1 //e t f a(/�'0/ I�/ ,�,A, y
ff n '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r� �'t � �'d Gj �r 17/���
(if well field,one lat/long is sufficient) 22.Certification: /
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6.Is(are)the well(s) Permanent or [jTemporary SignatureQ(-1,,-- .),,e,o
Certified Well Contractor ; >�ate(/
� By signing this form,I hereby cert fy that the well(s)war(were)constructed in accordance
7.Is this a repair to an existing well: 'f�f es or DNo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
' If this is a repair,fill out!mown 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: SUBMIITAL.INSTRUCTIONS 1
9.Total well depth below land surface: 1 U (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(g200'and 2@a I00') construction to the following:
10.Static water level below top of casing: (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: YJ to
� ) 24b.For infection Wells: In addition to sending the form to the address in 24a
r 7 d�r t above,also submit bile 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 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2-0 Method of test: f141b7 P 24c.For Water Supply&Iniectlol 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: '' It Amount ( C ti4 completion of well construction to the county health department of the county
t where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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