GW1--01452_Well Construction - GW1_20240301

Print Form' T1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1. ell Contra or Information:
/O (J /2 ,'l1 �^
il' v 1 r Pr i, Sc/I 14:WATER+ZONES , z 5�'
iFSOM Tp`) DESCR ON
"W 1 Contractor Name /6 2 ft. i/9 N. Off ,! Al eg/// G /
,w (((((((� YYff �? C t f�rT
NC Well Contractor Certification Number ft. 01 /lake t,c n
IS.OUTER CASING(for.multitased•wells)OR LINER'(if ap Ecable)`
Water Wizards Inc FROM TO DIA. TER T�i S hL2ERIAV
fL 3 d in. Sr, f Lfs4 Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)' - r '
2.Well Construction Permit#: FROM TO DrA11'{ETER THICKNESS
List all applicable well construction permits(i.e.UIC,County,State.Variance,etc.) 6 ft. ft (�A/ :r.<<�%I t;ii lj
rye
3.Well Use(check well use): H ft in. e ,-Z6
'17SCREEN
,. '
I Water Supply Well: •
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
jAgricultural 0 - .'cipal/Public ft. ft. in.
•
Geothermal(Heating/Cooling Supply) ita Residential Water Supply(single) n. ft. la,
Industrial/Commercial Residential Water Supply(shared)
18;GROUT,
Irrigation FROM 0 E LACEMENENT METHOD&AMOUNT
Non-Water Supply Well: Cdift 1C1C7 ftgzi �/f�%
Monitoring Recovery ft. ft
Injection Well:
ft. ft. '
Aquifer Recharge Groundwater Remediation
-19.SAND/GRAVEL PACKS(if applicable) .-- - =.-'
Aquifer Storage and Recovery Salinity Barrier T FROM TO MATERIAL EMPLACEMENT METHOD "
Aquifer TestStormwater Drainage ft.
it
Experimental Technology OSubsidence Control f. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additioosl sheets if necessary),ri
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM
ft TO DESCRIPTION(color,(color,hardness so8/rock type grain size,etc.) X
e� ft
4.Date Well(s)Completed:2/( 2C2G/Well ID# Aau 1''oI t -fr. f. [_ ISMS_ __
Sa.Well Loca on ft. R. h''�L:L/L i ��j t L d
3..d
DOfr.r '''it * e/ ft.
� �. ft. PEAR 0' 1 2024
F
ac
ility/Owner N1am Facility 1D#(if applicable) I
®/(t[ Ail// <'p ,1C i ft. ft. 1 Inioriraien Pr. ^.- t Unit
cal Address,City,and Zip Pp ft. ft. • 13WQ/�'uOC
County Parcel Identification No.(PIN) 1 G J ,(41,,vIL !i/!(��` ((44,-j� i®/�®I7
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 0 '/F ' /L l/p pP,' 1vo 4 ? eti.p c
(if well field,one lot/long is sufficient) 22.Ce ' catio
N W 2—i 2472 6/
6.Is(are)the well(s) Permanent or DT mporary Signature o Certified We C Date
By signing this form,I hereby cert(that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or �Ne with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repay 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: 1'
SUBMITTAL INSTRUCTIONS;
9.Total well depth below land surface: J 0 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(jdifferent(example-3@200'and 2@IQ) construction to the following:
10.Static water level below top of casing: 2 c Y4-5 (ft) 1 '
Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)
� 24b.For Injection 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: :I 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 Center,Raleigh,NC 27699-1636
13a.Yield(gpm) C Method of test: �/ A, 24c.For Water Supply&Injection Wells: In addition to sending the form to
+� the address(es) above, also submit 1 one copy of this form within 30 days of
13b.Disinfection type: % Amount: Z ('CI p r completion of well construction to the county health department of the county
where constructed. 1
1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016