GW1--00469_Well Construction - GW1_20240116

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
sjvH n 0 �er1 I ,
14.WATER ZONES I
Well Contractor Name FROM TO .DESCRIPTION
3oa y E j(o6 IPo v ft ao gPM
ft ft J
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased'wells)Ol (�f ap licable)
Water Wizards Inc FROM TO DIAMETERtS MATERIAL
Company Name 0 ft. V0 ft. 9 in. Sal qv V tom P1(�,p� 16.INNER CASING OR TUBING(geothermal closed-loop)
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2.Well Construction Permit#: W oC 3- 6-3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft. ft. I' in.
3.Well Use(check well use): ft ; 1 s.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
•Agricultural oMunicipal/Public ft. ft. in. .
•Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft in.I.
jib Industrial/Commercial DResidential Water Supply(shared) -
18.GROUT
—. Irrigation FROM TO - MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. It iu } Ce.i ,e,4- /.7e 16 S
SiMonitoring IDRecovery ft. ft I'
Injection Well: n �CXw
ft.
1 Aquifer Recharge Groundwater Reniediation 19.SAND/GRAVEL PACK(if applicable)
MI Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
•'Aquifer Test DStormwater Drainage ft. ft.
®Experimental Technology IOSubsidence Control ft. ft.
•Geothermal(Closed Loop) DTracer -20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) fi Other(explain under#21 Remarks) FROM - TO `` DESCRIPCIOK(coior,hardness soiUrocic type[Train size etc.)
i00 ft C200 n "re Qot*L
, 4.?Date Well(s)Completed: IIa-rya 3 Well hD,# ft• ft r— ^-- l-.:s _
ft ft g i C', i C
Sa Well Location:
��L el P es. ft tw IAN 2024
Facility/Owner
L
ner Name / r Facility Mt/(if applicable) ft ft
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-o d" N Poplar - ft ft Inform tit,^.11 t^`r^c�t:*i;:",2 llnYi:
ft ft I.A t.;:rtii.,1(a
Physical Address,City,and Zip Oro." a (�1 0 Cep 1 7-1�t tivo Ip r�
g 21.REMARKS
-1 o 7
County Parcel Identification No.(PIN) DC't '¢
11 deeper Cenci ner,) 1...1.70.4-er-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: bears n &. rie.c
(if well field,one lat/long is sufficient) 22.C 'on:
36. Isyai4g N 079+01Esaf5�(O W L l/ l -�4 is-it -a3
6.Is(are)the well(s) ermanent or [jTemporary Si of Certified ell ntracror I 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: Yes or i No with I5A NCAC 02C.0100 or 15A 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 weft owner.
repair under#2I 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 constrnction,details.You.may,also attach additional pages ifnecessary.
drilled:
,SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: a o (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: a 6- (ft-) Division of Water Resources,.Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
/ f � ,
)):.Borehole diameter: `O (iD) 24h.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: ICI:r Y 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 Mail Service Ceinter,Raleigh,NC 27699-1636
13a.Yield(gpm) eta Method of test:mow^ o p 11,A 24c.For Water Supply&Infection Wells: In addition to sending the form to
u (/� the address(es) above, also submit)one copy of this form within 30 days of
13b.Disinfection type: HT a -Amount: p Z . .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