GW1--01297_Well Construction - GW1_20240229

'Print Form ;=
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1. ellI Contract Information:
(&4O'l t W i f /j(i''1 t'G
Well Contrac� e FROM TO DESCRIPTION
7 ft. ft
fL fL
NC Well Contractor Certification Number 15. CASING(for multi-casedrWells)OR LINER(if a licable)""} ,
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
ft. fL , tn.
Company Name
=16:INNER CASING OR TUBING'(geothermal closed-loop).
2.Well Construction Permit#: FROM TO /� D R THt S ,MAT
List all applicable well construction permits(i.e.U1C)County,State,Variance,etc.) a ft 79 ft. " i in. .c. 1/7 p1//
3.Well Use(check well use): ft. it In. /I v
Water Supply Well: 17.SCREEN :e:._ , , .� ,�- %,,- ;.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0 , .icipal/Public ft. ft. in.,
Geothermal(Heating/Cooling Supply) _w 'esidential Water Supply(single) (t• ft in.,
Industrial/Commercial DResidential Water Supply(shared) 18..GROUT
Irrigation FROM TO/ MA L j LACEMEN ETHHOD ODNT
fL
Non-Water Supply Well: 7l/ Y (l�G�/ W7 /4�
Monitoring Recovery ft. ft. U /
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACIC(if applicable) '
Aquifer Storage and Recovery r3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft ft•
Experimental Technology 0Subsidence Control ft. ft
Geothermal(Closed Loop) OTracer :20:DItMLLING LOG(attach additional sheets if necessary)r'--- .-- ,
Geothermal FROM TO ' DESCRIPTION(color,hardness,soil/roek type,grain size,etc.)
(Heating/Cooling Return)7 Other(explain under#21 Remarks) fL [t
4.Date Well(s)Completed: I /f�G Well ID# ft. ft _
L
Sa.,We Oc ti L r\,C' E
ft f D
-- V P/0/ i ft. ,ft FEH 2 202 Facility/Owner Name /J act ty ID#(if applicable) fL ft
/>‘ Pa//art // L. t// ft fL if1tL`iBn jen Pf^C
i. �
Physical A s,City,and Zip / ft. ft.
Q (�
/fir/)
County Parcel Identification No.(PIN) _l, U 9 / i/1 r !mot/'► ,
'f T IJ1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ! / a / "P,, ,�� r/fry
(if well field,one lat/long is sufficient) 22.C 'o .
N W 'yG ! /%267
(j
Si tutu o e i
6.Is(are)the well(s)0Permanent or Temporary t onnactor 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: DYes or ONo with ISA 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. 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: (f) 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@l00') construction to the following:
10.Static water level below topof casing:►ng: ( ) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 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:
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) �
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY LLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: vl/yl,2 24c.For Water Supply&Iniection Wells: In addition to sending the form to
( the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 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 Revised 2-22-2016
r ,