GW1--00021_Well Construction - GW1_20231218

1
, . Print Form T 1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.W Contractor Information:
,g 1 /—Pi S re-Irj
14.WATER ZONES l i
WeilConuactorName FROM TO DESCRIPTION
Li tic _G ion" icy ' <6p lin
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Wizards Inc FROM DIAMETER THICKNESS MATERIAL
Company Name V f L WI ` i I S ) !d p p
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. i lo-
ft.3.Well Use(check well use): ; ra
17.SCREEN
Water Supply Well: FROM TO DIAMETER ' SLOT SIZE THICKNESS MATERIAL
iii Agricultural DMunicipal/Public ft. ft. In.t
r Geothermal(Heating/Cooling Supply) I]8t‘lential Water Supply(single) It. it. in.
1.Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 10 I 11- Pam . ) -"r,.3�( /�01(,
MI Monitoring X '•- •very fL iL � 0�
Injection Well: ft. ft.
•Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
NI Aquifer Storage and Recovery QSalinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
*Aquifer Test DStormwater Drainage R. ft. i
IN Experimental Technology IDSubsidence Control It. 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(rotor,hardness soil/rock type grain rig etc.)
11 ft. ft.
4.Date Wells Completed: I A42 )Well ID#A35/127 ft. ft.
() P ' ''fir, v "r:-\
5a.WellLocation: ft. ft. �—�' 1� ?z,,
Steven Smith ft. ft. DEC 1 ?Q23
Facility/Owner Name Facility ID#(if applicable) ft ft.
100 Hassel Clayton Rd {� ln` .... '��
� ir) X'C I a�cny ft. ft J Qvde'•';?ti A
Physical Address,City,and Zip ft. ft ,
Person 21.REMARKS - -
County Parcel Identification No.(PIN) I(-Red 1 t 3 (-dr I o
I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: it
(if well field,one lat/long is sufficient) 22.Certification:
36°,a-47:2Q N7'°0 ' 31',414' 'w d II1310-' )
6.Is(are)the well(s)Irmanent or Temporary Signature of Certified Well Contractor ' Date
�� By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: L' s or [ No 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. I,
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 ii needed. Indicate TOTAL NUMBER of wells construction details.You may also attach additional pages if nPtPcsaty.
drilled: j/ /� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 11 O (fk) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths'([different(example-3Q200 @a0'and 2 100') construction to the following: 1
1
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: 4 (in.) 24b.For Infection Wells: In addition on to sending the form to the address in 24a
`,� f , above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: F0TI 1 construction to the following:
(Le.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �J Method of test: p vrx? 24c.For Water Supply&Iniectioni 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: I Amount:_6 60-6,6 completion of well construction t e 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