GW1--01455_Well Construction - GW1_20240301

Print Form 1
WELL CONSTRUCTION RECORD(GW-I), -:i•= '',,' For Internal Use Only:
1.Well Contractor Information: -"'
ZI vi o f ,' , 14.WATER ZONES
Well Contractor
N//a��me i - - FROM TO DESCRIPTIONy.
.30P4 -. ,\ D ft. lc'ft. 2..
�pa'/ 1
NC Well Contractor Certification Number z,®ft. / oft. 4/e fh01
15.OUTER CASING((for mai -caseded wells)OR LINER(if ap lcable)
Water Wizards Inc FROM TO DIAMETER I THICKNESS MATERIAL�/�
Company Name 0 ft L) ft 6 1C_1 in. IC ,2! v 14.,
OSWP-00346-2023 16.INNER CASING OR TUBING(geothermal closed-loop)se
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
• List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft ft I in.
3.Well Use(check well use): ft. ft. I is
Water Supply Well: FRROSMCREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
111 Agricultural Q icipal/Public ft. ft. In.
11 Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
III Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL / EMPLA METHOD&�AJMOUNT
Non-Water Supply Well: D tL 0, fL .3,�II ®!Q / pD/
N Monitoring IORecovery tit ftd f/4GG
Injection Well: ft. ft
I Aquifer Recharge I Groundwater Remediation goo/ps
19.SAND/GRAVEL PACK(if applicable)
It Aquifer Storage and Recovery OSalinity Barrier FROM , TO MATERIAL EMPLACEMENT METHOD
I Aquifer Test 0 Stormwater Drainage ft. ft. ..
Ill Experimental Technology OSubsidence Control ft. ft. I
II♦Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) it Other(explain under#21 Remarks) FROM TO DESCRIPTION Ion hardness soil/rock type,grain size,etc.)
A99/270 0 - 7ft ogee tef4✓1
4.Date Well(s)Completed:)'�'Z ei Well ID# f ZDQ ft ejej . /,
5a.Well Location: Ayr ft.
AO ft. enec y >r0[.ill
Elise Ayers , ft. ft '
Facility/Owner Name Facility ID#(if applicable) ft. ft -�„ i 7'
7465 Range Rd Rougemont NC 27572 rt. ft. - "` a '�"'
Physical Address,City,and Zip ft. ft MAN Z U L`t
Person 21.REMARKS ' ,i
Info:r..r4tin Prr.4.04=4(}nit
County Parcel Identification No.(PIN)
CWQ/
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) Q Q Q/�p� 22.Ce ' cation: ',,u A.Pliscc N -7g• 82419ag W C 3 .4 ?-iy-24f
• 6.Is(are)the well(s) rmanent or Temporary Signa ofC ell 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: Oyes or !_?r`� with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constriction 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:
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: �f_ 0 SUBMITTAL INSTRUCTIONS r
9.Total well depth below land surface: !/4 (ft-) 24a.For All Wells: Submit this j form within 30 days of completion of well
For multiple wells list all depths ifdiiferent(example-3Qa 200'and (Qa 2 10100') construction to the following: '
10.Static water level below top of casing: 24. (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing:use"+' �j�. 1617 Mail Service Center,Raleigh,NC 27699-1617 '
11.Borehole diameter: Vr " P (m) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: kID eabove,also submit one copy of this form within 30 days of completion of well
/ construction to the following: ! '
(ie.auger,rotary,cable,direct push,etc.) I ;'
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) i..7 Method of test:8(008% 6 #v('724c.For Water Supply&Infection'Wells: In addition to sending the form to
L the address(es) above, also submit one copy of this form within,30 days of
pi 7_
13b.Disinfection type: fri Amount: l2-Don 44- completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016