GW1--01459_Well Construction - GW1_20240301

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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Ii Contract° ['formation: `II ` C'd
j / /h 14.WATER ZONES i
Contractor_ FROM TO DESCRIPTION
Well Namef. ft.
27 ft ft. 1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(If ap licable)
Water Wizards Inc FROM TA 4. D Tffi Es fimi/A?
Company Name ft.
/n7io �L 'Cie,
J I /�� 16.INNER CASING OR TUBIN (geothermal closed'-loop).
2.Well Construction Permit#: 7)3eQ(-1—00 13 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(e.UIC,County,State,Variance,etc) ft. ft. in.
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3.Well Use(check well use): h ft �' in.
Water Supply Well: 17.SCREEN u
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
11 Agricultural QM cipal/Public ft. ft. In.,
I Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. is,
11 Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: H. ft
I Monitoring ORecovery ft. ft. -
Injection Well: ft.
11 Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
',Aquifer Storage and Recovery DSalinity Bather FROM TO MATERIAL EMPLACEMENT METHOD
11 Aquifer Test IDStormwater Drainage ft. ft.
•Experimental Technology EiSubsidence Control ft. ft. ,
1 Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
GeothermalFROM TO DESCRIPTION(color,hardness,soil/reek type,grain size,etc.)
(Heating/Cooling Return)(' Other(explain under#21 Remarks) ft ft
4.Date Well(s)Completed:t 252Z/ Well ID# ft. f '
5 Wel�f°°cation: ty- .
/ R R ,";''r P fir'rtt&r Io( ft. ft. ,e 1..c �,F il' /Owner Name ^� 4,17
lac''ty ID#(if applicable) ft. ft MAR
U 0 y 21174
t �/2 C za j diernft. itHR A t 1 4
P((((hyaiiJJJiccaIAddsess,City,and Zip vvv ��/��X/// ft. f. 4fh.riY'1:i ic^il Jr: doTSi:(;t�a iJB#r
/� 21.RE ARKS DWQ/!�C
County r Parcel Identification No.(PIN) e l(1� lm25b.Latitude and longitude in degrees/minutes/sewnds or decimal d ees: ,P, G ( s / to/�i
(if well field,one lat/long is sufficient) 22. tZ
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N W / �l. 1✓;�-�O
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Well Con Date
Sy 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 E3No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy of fhb.record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 1
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.
filled' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2 2- �" (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 a�i 00'and 2Q100) construction to the following:
10.Static water level below top of casing: (1/r[G' (ft.) Division of Water Resonrces,.Information Processing Unit,
If water level is above casing use"+"p 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in-) 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: 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) _ Method of test: th/h 24c.For Water Supply&Injection 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: f j Amount: completion of well construction tot the county health department of the county
where constructed. I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resourcies 1 Revised 2-22-2016
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