GW1--01453_Well Construction - GW1_20240301

i Print Forme!
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Con ctor Information:
6/0/1 ` C6 IA I I f`� SW 1 14.WATER ZONES
FROM
DESCRIPTION
'Well Contractor Name 176 ft r..' f
Z 7'76 /1 ll fw /.Z C i
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Wizards Inc FROM TO DIAMETER Twiner..s MA`X' }'
Company Name C1 ft. 5�R. fit in. f K /o/.,/
16.INNER CASING OR TUBING(geothermal closed400p) fs V-
2.Well Construction Permit#: FROM' O D TER THI ,� . MA
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) /'A ft. f el& in. ce - ' .'
3.Well Use(check well use): el f� Vv ((( �'Y' V
Water Supply Well: 17.SCREEN
� FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ilt 1'
Agricultural _ ctpal/Public f. ft. In
111 Geothermal(Heating/Cooling Supply) J esidential Water Supply(single) ft ft. in.
111 Industrial/Commercial OResidential Water Supply(shared) '
18.GROUT
I Irrigation FROM o ACEIVIIEINy METHOD&AMOUNT
Non-Water Supply Well: 0 ft /175 ft. t 4°//71;r
all Monitoring Recovery ft. ft %%%
Injection Well:
ft. ft. 1
ll Aquifer Recharge D Groundwater Remediation '
19.SAND/GRAVEL PACK(if applicable) '
III Aquifer Storage and Recovery DSallnity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
*Aquifer Test DStormwater Drainage ft ft !
a Experimental Technology DSubsidence Control ft. ft. .
111 Geothermal(Closed Loop) DITracer '20.DRILLING LOG(attach additional sheets if necessary)
I Geothermal(Heating/Cooling Return) [mother(explain under#21 Remarks) FROM TO DESCRIPTION(robe,hardness,soil/rock type,grain size etc.)
ft ft
nn y
4.Date Well(s)Completed:Z-/ -lam.C2 Well ID#A ILIA I l a ft. ft. ;' :'a^''";"'G ,TM
r ft. ft .t''�`�..e d �
5 Wellfii0n U ��
iVT144ck, ft ft MAR (� 1 2024
Facility/Owner Name Facility m#(if applicable) tt ft f
�, /�1 1 P/1'f�lGl ft. ft. Dtkit�:Tte� .
Ph ical Address,Ci and Zip ft ft.
refro)1 2 .REM
County Parcel Identification No.(PIN) q rdr/,Ali. f/ � 4.1,1-) w�./
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: / r t
(if well field,one tat/tong is sufficient) 22.Certificatio . .
W ig, -2--4-2o2X
6.Is(are)the well(s) Permanent or D mporary Signature of Certified Date
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By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or No with 111 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fdi 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: G �/ SUBMITTAL INSTRUCTIONS !•
9.Total well depth below land surface: 1 II
, v 00 24a.For All Wells: Submit this{form within 30 days of completion of well
For multiple wells list all depths ifdi,Berent(example-3Qa 200'and 2Qa 100.) construction to the following: i
10.Static water level below top of casing: ® (ft.) Division of Water Resources,.Information Processing Unit,
If water level is above casing,use 1617 Mail Service Cenier,Raleigh,NC 27699-1617
11.Borehole diameter: )710 24b.For Injection Wells: In addition to sending the form to the address in 24a
P/( P above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1 construction to the following: '
(ie.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) /f Method of test: 24c.For Water Supply&IniectionI 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: P Amount: .el f completion of well construction to`'the county health department of the county
where constructed. i 1
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 7 ; Revised 2-22-2016
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