GW1--01454_Well Construction - GW1_20240301

Print Form 77
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
( ) I L.e., ' ( yam TC
14WATER ZONES ;.:. 1 asa
Well Contractor Name FROM TO DESCRIPTION
H C{5 G j ift. l0e9..ft. ')�'
ft ft i
NC Well Contractor Certification Number v15.=OUTER.CASING'(for multi-cased'Wells)OR LINER(if ap llcable);:-
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. ft. to �✓' ` G
U
-16cINNER,CASING.OILTUBING(geotlieruml closed-loop) . q••',_,
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(I.e.UIC,County,State,Variance,etc.) ft ft I in,
3.Well Use(check well use): ft. ft is
Water Supply Well: ;17.SCREEN . _ ",,,,, + •:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMu ipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) Of Water Supply(single)
ft ft. In.
Industrial/Commercial a Hfd9 18 GROUT, . ``
I. Irrigation FROM TO MATERIAL EMPLACEMENT M OD&AMOUNT
Non-Water Supply Well: 0 ft 1a P a--, , Pam„ / J 5d/L s
Monitoring ecovery ft ft.
Injection Well: ,
f. ft
Aquifer Recharge OGroundwater Remediation
19:SAND/GRAVEL PACK(If applicable) µ' '.,',.'it _,;'
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD_f fl
Aquifer Test 9Stormwater Drainage ft ft ;
Experimental Technology DSubsidence Control ft. ft. ;
Geothermal(Closed Loop) Tracer '20 DRILLING LOG(attach additional sheets:if necessary),-:-rr,
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
4.Date Well(s) FROM TO DESCRIPTION(color,hardness,soilrock type,grain sire,etc.)
i6a-i / ft ft
Completed: Well ID# IDS �� ft. it
�' ,
5`a Welli Location:
,/ ft ft t,,yr„c ^,-. f
a vAN 'r`/ �,A f ft. ft ; A y'`R1'
Facility/Owner Name �,,/���'�1 Facility lD#(if applicable) ft ft MAIM ) 11UZ4
L( i/ I ' eiOV\ ),t, .•c.ioe ft ft mF,�rrrl*z'iFn Pr�C_yGS•�
Physical Address,City,and Zip ftft.
ft.
pe Oh. ;21::REMARKS , /,
Codny Parcel Identification No.(PIN) l r. 'i , QJ t^ C' 'e-t;TC' i 9
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (C '
(if well field,one lat/long is sufficient) 22.Certification:
3 iLi ') OQ N -7 eye{ e:r 5i 4 W r < r\t,
6.Is(are)the wells) - ermanent or Temporary Signature of Certified Well Contractor Date
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: es or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fell 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 GAT-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: i(WC) (ft.) 24a. For All Wells: Submit this;form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 200'and 2Q1001 construction to the following:
10.Static water level below top of casing: t (ft,) Division of Water Resources,Information Processing Unit,
If water level is above casing,use' 1617 Mail Service Center,Raleigh,NC 27699-1617
�� I
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: fol�,� -A../ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) 1 I
i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
''✓
1
13a.Yield(gpm) I v^^J Method of test: A V v l 24c.For Water Supply&Injection Wells: In addition to sending the form to
II� //',,, the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: 14-4- IT' Amount: lodw1,4--"--< completion of well construction to 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