GW1--01457_Well Construction - GW1_20240301

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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(j� PROM WATER ZONESI I
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vvv �j� FROM TO DESCRIPTION
Well Contractor N " " I/n / ����1
NC We ntractor Certification Number / 7U
15.OUTER CAS G(for multi-cased',wells)OR LINER(if ap licable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
o ft. tt. b si0 Z1 fV
Oompany Name y� 16.INNER C LING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 3 V S (� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pennits Le.UIC,County,State,Variance,etc) ft ft- 11 in.
3.Well Use(check well use): ft
Water Supply17.SCREEN 'r 1
Well: FROM TO DIAMETER' SLOT SITE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in
Geothermal(Heating/Cooling Supply) D5midential Water Supply(single) fL ft. in
Industrial/Commercial iffResidential Water Supply(shared) 18.GROUT I
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AM UNT
Non-Water Supply Well: ) f. Q ft. 3/ 1' ']� is6.....5.2/e)c-ce,f/ T7l/ l� r C�1
MonitoringRecovery ft tL . /i( n f r i
Injection Well: ft. ft. T ( �OO"^ /9�®9r/
64 Aquifer Recharge DGroundwater Remediation '
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test (Stormwater Drainage ft. ft ,;
Experimental Technology IDSubsidence Control ft ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soWroek type,pain size,etc-)
0 ft 7 ft- /904401,e-101
4.Date Well(s)Completed: I --2Z'2 (Well ID# T7 ft 157 ft' t✓COY
5a. ell Location: f p1 it,1ft E�1 tl �F3
gre I 420,r- /40 0'1--e--5
Facility/Owner Name Facility ION(if applicable) ft. ft - '? 2
�' ft. ft. a ,4i.. ii.�i tU
Physical Address,City,and Zip Z72-3 i ft ft.
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©ri,y\ {_ qg 1 C-2 L�J0/4 21.REMARKS i, . VD) 2024
County J Parcel Identification No.(PIN) info:WW2.ir'n P'"', t'a(,i9')"i -
�. DWQ/30G
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: ;
3(o�t1 'Ci'91 - 79®g'/ld .�2 $2 L ( , - ,, 7."l
6.Is(are)the wel(s) rmanent or Temporary ! of Certified We Co or I 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: DYes or EX with ISA NCAC 02C.0100 or ISA NCAC.02C.0200 Well Construction Standards and thata
If this is a repair,fill out known well construction information and explain the native 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 nweessary.
drilled: SUBMITTAL INSTRUCTIONS I
9.Total well depth below land surface: I (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
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10.Static water level below top of casing: /�7 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing;use"+" t n 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: �4- (n. i
24b.For Infection 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 �ii�� 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:/ 9 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 6 test: J/A i_0
� Method of �/6t. r�i,.s14c.For Water Supply&Injection Wells: In addition to sending the form to
�j Q the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection type: /1)1 Amount: i e,L..re. , 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