GW1--01456_Well Construction - GW1_20240301

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Wc...k 4 i 1'SG14 14.WATER ZONES 9 i'
Well Contractor Name FROM TO DESCRIPTION
�758" G 116 >L J 11 ft. 6 G-tPrw
ft. ft.
I 1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name O ft. 165 ft.
1..� !,is SC*
Lib
b Q I f/�
t/14r 001\ 16.INNERCASINGVORTUBING(geothermallclosed-ll0000p) I V!i
2.Well Construction Permit#: FROM TO DIAMETER. THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft , in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgriculttual DMunicipal/Public ft. ft. In.
DGeothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
[jlndustrial/Commercial reesidential Water Supply(shared) I8.GROUT, ' - •
flfrrigation FROM TO MATERIAL - EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. a OS ft. N6Ar'' 41S0 I bs Formze D
Monitoring IDRecovery ft. ft.
Injection Well:
ft. ft.BI'
Aquifer Recharge DGrotmdwater Remediation :_ __19.SAND/GRAVEL PACK(if applicable)' ' =_ _"'Aquifer Storage and Recovery OSalinity Bather FROM TO MATERIAL , EMPLACEMENT METHOD
IjAquifer Test 0 Stormwater Drainage ft. fL
DExperimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) (Tracer 20.DRILLING LOG-(attach additional sheets if necessary) _ -
flGeothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sowrocir type,grain size,etc.)
ft.iL
I
4.Date Well(s)Completed: -I 7-281 Well ID# ft. ft.
Sa.Well Location: ft. ft. ""•j a :y *"
/94PR EA ERV Es ft. ft. €.a a '�Via"
Facility/OwneerrlName p G Facility ID#(if applicable) ft. ft. M A R 0 1 ZU 24
2143i /Zze4li4 b L.ftlI ft. ft. ` ��.,�I
Physical Address,City,and Zip ft ft KIWI��own,...+/QI5OG V""
On.41.1Crbe C p l-I S'31416V 21.REMARKS I'
County Parcel Identification No.(PIN) 1 A1STALL eD LTNjlis1i 13/C L.t:AI.1.Tnje,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1962.14Q) or Jo). Pe 4 T
(if well field,one latflong is sufficient) 22.Certification:
36. I So r Zob N -.7` .60ros 05.7 W /Ll Gdc Otfiksc� ), I? -.24
6.Is(are)the well(s)iermanent or Temporary Signature of Certifi Contractor i Date
'y
By signing this form,1 hereby certfb,that the-xuU(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [es 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. i
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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 0 (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 2®100') construction to the following: I
10.Static water level below top of casing: So (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing use"+/" 1617 Marl Service Center,Raleigh,NC 27699-1617
V 11.Borehole diameter: l4
(in.) n 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: RorAlt y above,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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 6 Method of test ALM Q 24c.For Water Supply&Iniectil nl Wells: In addition to sending the form to
1 the address(es) above, also submit one copy of this form within 30 days of
,13b.Disinfection type: 147 I4i' ` Amount: O Olt. 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 I. Revised 2-22-2016