GW1--00028_Well Construction - GW1_20231218

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i
i
1.Well Contractor Information:
Irt c't D 14.WATER ZONES ! !
Well Contractor Name - FROM TO DESCRIPTION
e).21-1/ ZS ft. 70 rt ) �6'fel
NC Well Contractor Certification Number " .�G Z�Q ��
15.OUTER CASING(for multi--cased wells)OR LINER(if ap licable)
Water Wizards Inc FROM TO DIAMETER' THICKNESS MATERIAL
Company Name 0 ft. O ft.
9 ! in. 341,
1 J0 P V
W23-0154 16.INNER CASING OR TUBING(geothermal closed-loaapp) , -
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.
ft3.Well Use(check well use): I 5n
Water Supply Well: 17.SCREEN
FROM TO DIAMETER: SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. rt. in.;
Geothermal(Heating/Cooling Supply) D esidential Water Supply(single) ft. ft. In.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft 6 H ft 3/4''/fo _ &5
Monitoring DRecovery ft ft % ` r
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DiSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence 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 rotor. m sowroektype grain size,etc.)
4.Date Well(s)Completed: I(""/.7-43 Well IDl1 7 ft. Li 25.. c le....,, �/�
5a.Well Location: u�ft. ®' ft. cnr 6 2i t�J�0 J
Yates Homes ft ft. ' nt,„s }. ''. ;.',-.y��
,.. s '
Facility/Owner Name Facility lDil(if applicable)
ft. ft. �_.,
5570 Normans Rd Rougemont NC 27572 ft. ft. ' DE C 1 ?n, 7
Physical Address,City,and Zip p n Fft. ft. ' Ir i Ji; _.; ..Dr'^ C}
Orange _ 07JQ 2O f 80(-,7i 21.REMARKS /'3'. ., .--.:' a ry '.
County Parcel Identification No.(PIN)
1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wellfield,one lat/long is sufficient) q q/ p' �/ 22.Ce;Lyn:
36s, / 1 D 2? N r 7 g, / / (�C7 1 9 W if- II -2-3
6.Is(are)the well(s) rmanent or Temporary i of Certified Well o ct 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: OYes or No 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 la the see!!ouster.
repair under 421 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For GeoprobelDPT 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 nerresary.
drilled: zt� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ✓V E) (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@I00') construction to the following: '
10.Static water level below top of casing: 2" (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing.use"+"�QQ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (9U (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: 6e0 frr� above,also submit one copy of this form within 30 days of completion of well
�N construction to the following: II
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:7o� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 61Ot.IVL ♦u'I�For Water Supply&Injection Wells: In addition to sending the form to
/� o, the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: h [ /111 Amount: /q OLt„C e.fc' 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