GW1--00468_Well Construction - GW1_20240116

•
-_ Print Form-T
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1
1.Well Contractor Information:
'T 1 1
1.►v% 0 14.WATERZONES .i. t
FROM TO DESCRIPTION
Well Contractor Name 02.5
3 V 2j1 �ft. ft. ( Mlffrli
ft ft. !
NC Well Contractor Certification Number '15.OUTER CASING(for multi-cased:wells)r R LINER ' ap.licable) '
Water Wizards Inc FROM TO DIAMETER .,w-. S MATERIAL
Company Name 19 ft ft- '1 I' in. L! L, Q pt/�
. ' 2 ^/ 16.INNER G OR TUBING(geothermal closed-loop) t/ •' 'a
2.Well Construction Permit#: ►4j 2- "07$� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Countyy,State,Variance,etc.) - ft• ft- j in.
3.Well Use(check well use): ft. ft 1 .
17.SCREEN
Water Supply Well: FROM TO DIAMETER 1 SLOT SIZE THICKNESS MATERIAL
Agricultural 0 ' ipal/Public f, ft. in.
Geothermal(Heating/Cooling Supply) Z'Residential Water Supply(single) ft ft in.,
IndustrialICommercial 011esidential Water Supply(shared) 18.GROUT _ .
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft /a, ft. t/'.Goal-C"..n+,Ln.�/ -700
Monitoring DRecovery ft ft.
Injection Well: pock.`
ft it
Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL ' EMPLACEMENT METHOD
_.Aquifer Test DStormwater Drainage ft ft•
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional;sheets if necessary)
Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) FROM P�TO DESCRIPTION(color,hardness,saiViotk type,Grain she,ate)
Iwo ft v( (crci rot k
4.Date Well(s)Completed:12-Z/?3 Well ID# ft ft. /
5a.Well Location: ft ft- • tTh 0 g P i.--.,.,
�� ��t�,n Z f. ft i4''''' `PL i V tLi
Facility/Owner Name Facility ID#(if applicable) ft. ft JAN 1 6 2024
t 72,D I) ,0 p iatr 1 . 1-1; I(,LL< l ft. ft .
Physical Address,City,and Zip it C 2:7- 7,6 ft. ft. ln,ar.:.s;«.n sarr,,C: „fA.2 UAN .
1$ 17y�-6z57 21.REMARKS ,j ; °.Z`c:,,
®C�.,,e P r0 J lea et- ' //�� ry Q /�
County J Parcel ide�ificationNo.(PIN) r �Z>r 7w mil'-.M'\ i p.�t.)' („r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: b-'r °• i S />t'`/I'e at /,.itif
(if well field,one latflong is sufficient) 22.Certification: 4kPke j((,t5 Ot u/ ole, /7 NGal-
3('' (9�/g�1' N _ 77. D/ '2393 w /.
6.Is(are)the wells) Permanent or Temporary 40°
ertified Well r`.,r,,(9.c r 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: QYes or 1Yo with 1SA 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 under#21 remarks section or on the back of this form. d,
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 ,
9.Total well depth below land surface: ©0 (ft) 24a.For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if-different(example-3@200'and 2 e@100) construction to the following:
g'
10.Static water level below top of casing: k �
5 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing;use"+"t II 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter. GY (m.) 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: 1
/ 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
1 (� t
13a.Yield(gpm) / Method of test:rt3( t.J Yl 2400v,7 24c.For Water Supply&Injection Wells: In addition to sending the form to
the addresses) above, also submit f one copy of this form within 30 days of
13b.Disinfection type: 1-1-1 Amount: ©Wn rnf/1 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016