GW1--00027_Well Construction - GW1_20231218

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1 ell Con ctor Information:
gfavl Gm IAA 1 1:4 M Sryei
14:WATER ZONES I
Well Contractor Name FROM TO n cRIPTI x
2_7 q 6 ,4 q- ft. eq. ft. p6 (,4, ro c,/,,,
( 77ft. (ft• d)ll, Wd A. 7d/7r
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Water Wizards Inc FROM TO D 7'ER Tm ,SG MAC
Company Name U. ft. a ft , rm c i/
W23-0267 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 1n.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
if Agricultural OM cipa1IPublic ft. ft. iu.
R Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft, ft. in.
111 Industrial/Commercial QResidential Water Supply(shared) 18.GROUT
I Irrigation FROM TO � CEMENT METHOD&AMOUNT
Non-Water Supply Well: /oG ft O. ft* J✓o � pA, 7- 5016 btu
I Monitoring IDRecovery ft. ft.
Injection Well:
ft. ft.
11 Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
al Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
If Aquifer Test IDStormwater Drainage ft, ft
If Experimental Technology IOSubsidence Control ft ft
Ill Geothermal(Closed Loop) DTraccr 20.DRILLING LOG(attach additional sheets if necessary)
•Geothermal(Heating/Cooling Return) []Other(explain under#21 Remarks) FROM IL TO DESCRIPTION(color,hardness,sotWr ck type,grain she etc.)
ft.
4.Date Well(s)Completed: 11 J`3o-202/3Wen 11# ft. ft.
Sa.Well Location:
Eric&Martha Secor ft. ft. ' ;'
Facility/Owner Name Facility DM(if applicable) ft. ft - f, t''.,7`. )rf-
610 Sinai Circle Hillsborough NC 27278 it. ft• [jl.(, j c `013
Physical Address,City,and Zip ft it !n i,,,----... _.
Orange 21. rAms
County PaicelIdentificationNo.(PIN) /'N 4.ll�� ��, r/ u/
r ''f
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: )p pG r/ 7" ""!(�'�ra G, d. ,y'Df if z`he
(ifwell field,one lat/long is sufficient) 22. a cati . ,
N W • dJ �' 1I-3G2G2-3
6.Is(are)the well(s) rmanent or Temporary Signature of Certified We ctor Date
� By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: I�a s or E3No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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 II ,
SO49.Total well depth below land surface: I �7 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@100) construction to the following: i
/y I
10.Static water level below top of casing: v (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: (e) ("L) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Di, I J/tom 04 construction to the following:
(ie.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,jUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) j Method of test: Pelfirlf 24e.For Water Sunnis,&Injection Wells: In addition to sending the form to
/��// � the address(es) above, also submit jone copy of this form within 30 days of
13b.Disinfection type:( 1` ( ar-,A,Amount: -CGf f completion of well construction to the county health department of the county
(I l where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource Revised 2-22-2016