GW1--01450_Well Construction - GW1_20240301

1
i Print Form 1
WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: ,
1. Contrac o Information:r /
lC W //i24/ h <t p� 14.WATER ZONES i
pit
Name FROM TO DESCRIPTIO ;
7 ft n /� ll �.GAP ''"1-t //
�� ft. ft
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)' '
• Water Wizards Inc Imo TO DIA11 THI /s MA
� IL q ft in. cr` v C9r// �t//,
Company Name _
16.INNER CAS1N OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER . THICENEyS� MA
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft* 1 ft' f� In Q,/� /7/ tiC
ft.
3.Well Use(check well use): fL ((YY :1°•
Water Supply Well: 17.SCREEN:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural OMpicipaUPublic ft. ft. la.
0Geothermal(Heating/Cooling Supply) - esidential Water Supply(single) [L ft in.
Dlndustrial/Commercial Residential Water Supply(shared) 18.GROUT . - - _
I!1n'igation FROM TO ` CEMENT oD/8;c Qd1j0
Non-Water Supply Well: 0 ff.
6/ ft. pt /�r/Gt1 l C7t
Monitoring IDRecovery f. ft. I '
Injection Well: ft. ft.
E}Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable) •_._ _-
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test jStormwater Drainage ft' ft.
Experimental Technology Subsidence Control it ft j'
Geothermal(Closed Loop) OTracer -20.DRILLING LOG(attach additional sheets if necessary) '' ' - - - ' ' -
Geothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardness,sell/reek type grain sae etc.)ft. ft. i;
I
'7�4.Date Well(s)Completed: -d `z 2 ell iD#f 2 s I�J(..O ft. ft. ,, ; ice`^ `i /""^y
ft ft. •'�‘.."I....i r4' tLi
�5a W D_L /
f C7on:� (>° / c0 ft. MAN �l 20Z4
Facili� er Name Facility Mi�t if applicable) ft. ft.?(j/7 MC 61,. ( I i'// Ve ft ft. ' til:fll�,.or� o%' .�.c ,2 umPhys l Address,City,and Zip N. ft.
/
County Parcel Identification No.(P� h 01//eit,(/` �� !/�! �G J'''
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ��� ' �1� ��(��
(if well field,one tat/long is sufficient) 22.C lion: '
N
W
j______ 2 '—-/—-2 2.y
6.Is(are)the well(s) Permanent or DT mporary Signature of • we Contracror Date
By signing this form,I hereby certify th i t the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or ONo with 15A NCAC 01C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is et repay,fill out(mown well construction information and explain the nature of the copy ofthis 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 nececcary.
drilled: SUBMITTAL INSTRUCTIONS ;
I.
9.Total well depth below land surface: / C (ft-) 24a.For All Wells: Submit this;,form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 a@200'and 2(a1100') construction to the following: I .
10.Static water level below top of casing: 7 0 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing use"+""n 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: "tom (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: �/ (/� construction to the following: S
(ie.auger,rotary,cable,direct push,etc.) I '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) fr' A4' a,4.mount:
thod of test /i 24c.For Water Supply&Infection 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: l cI,& completion of well construction tti the county health department of the county
where constructed. I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources, ' Revised 2-22-2016