GW1--01451_Well Construction - GW1_20240301

Paint Form ,_ 1
WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Con for Information:
lrU/ %01 / rm`//t. ..fin s6 4 WATER ZONES
Well ContraclorN FROM TO DES N'
2 7: 00 ft. ft- 1( 9,/ 1fe��14cP
t G ft. ft
NC Well Contractor Certification Number. .15 OUTER CASING(for,niniti-cased wells)OR LINER(Ifrip"livable) :,-
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
ft- ft. In.
Company Name
16 INNER CASING OR TUBING(geothermal closed-loop)` _ V'.
2.Well Construction Permit#: FROM TO DIAMETER TH CICNt7 MATERW,
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) V ft. 7 V ft. C',,i in. ( h1 `i'//� F q / C�
3.Well Use(check well use): v ft. V ft J In. J V v
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
a Agricultural icipal/Public ft, ft in.
'•Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft, In.
*Industrial/Commercial DResidential Water Supply(shared) ,
Irrigation FROM TO • EMPLACEMENT METHOD& OUNT
Non-Water Supply Well: �f ft- o ft- PcA/ra Pn.4// L/GO/1ill Monitoring Recovery / ft. ft •
Injection Well: ft. ft. ;
•Aquifer Recharge OGroundwater Remediation
ill Aquifer Storage and Recovery Salini Barrier ',19•SAND/GRAVEL-PACK(if applicable) , ' '.4' '�•�` •,
tY FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ID Stormwater Drainage ft ft ,
111 Experimental Technology DSubsidence Control'} ft. ft.
))*Geothermal(Closed Loop) OTracer -20 DRILLING LOG(attach additional sheets if necessary)'
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sae,etc.)
( gl g I Other(explain under#21 Remarks) ft ft
4.Date Well(s)Completed: Well ID# Ads() k'L2(, ft. ft. f. ^-, ,.
�t_" i
5 .Well cation: / J ft. ft. I3
o (// 04 L/1o"I`�' ft. ft. MAR I) 1 7074
Facility/ erName / l Facility #(ifapplicable) ft. ft.
PV �Gf l f'� ih11I />r ft ft l,liprrla l • ;..:; ;11 wltt
P ical Address,City,and Zip ft ft
1)407(0/1
21: l l
County Parcel Identification No.(PIN) L f/!0J///e /r �0�,/`�_,(,„,1_,,L `��17 �a
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ((( f / i >1e/ / It (tea"r°�c 0c/'7
(if well field,one lat/long is sufficient) 22. .rcatio /
N W G/S� / /- 2
6.is(are)the weU s Permanent or Tem ora Sign of rti6ed W ctor ; Date
• By signing this form,l hereby certify that the uell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: JYes or ONo with ISA 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. 23.Site diagram or additional well details:
You may use the back of this page,to provide additional well site details or well 8.For Geoprobe/DPT or Closed-Loop Geothermal'Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I / SUBMITTAL INSTRUCTIONS I.
9.Total well depth below land surface: I f U (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@/00'and 2@100') construction to the following:
10.Static water level below top of casing: / 0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use/':k" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: lU (in) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: (21//�D
above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) S.G ? Method of test: (My 24c.For Water Supply&Injection.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: /- 2 Amount: —(Cr S completion.of well construction to tie county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources . Revised 2-22-2016