GW1--03045_Well Construction - GW1_20240520

Print Form
r--
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contr for Information:
/ 0141 Gh VV)' //r4,/h <G,n ` 14.WATER ZONES
Well Contractor
/ ! r/Name t� r Y� r'o uRIP t9o4K /
Y Zit. (�� [/r�� � �'1
f4 ft
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wells)OR LINER(if ap lieable)
Water Wizards Inc FROM TO DIA ETER TTHIC N S�(/� MATE '/
e ft. a ft. (0 in. t q- ) 9cr tV
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DI METER IC Esf MATS
LiWelal Cocablelc Ptrcit#: ft 7 / � `�, (- � /
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) v (� (,(/ 1O'
3.Well Use(check well use): ft ft in.
17.SCREEN
Water SuFROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Well: DM icipal/Public rt. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
irrigation FROM ' TO 'AtA 'afPLACEMENT METHOD&ArgUNT
Non-Water Supply Well: 7 ft- rot ray 2 5.6 / I
Monitoring DRecovery ft. ft.
Injection Well: ft et.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft•
Experimental Technology [1Subsidence Control ft. ft
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Coolin Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rocktype,gram size,etc.)
4.Date Well(s)Completed: 2 ID'"2 VWell ID# ft• ft.
r_. . r .
ft. ft.
$a.Well L anon . : --i. r 4, 4 _ -
Facili /Owner Na ! /�/ Fa ity ID#(if applicable) ft. R 2 V C t
1 � J >,,,,,/, G, , ft. ft
PI Ad ,City,and Zip
ft fL G'1 i:,' ,3.;
ilidir U/11
21. i//4 , "-.1County Parcel identification No.(PIN) 1 ��/[(�� 1/ i/ �� K5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certi 'on:
N W -21D-2
6.Is(are)the well(s) Permanent or DT ovary Signature of Certifi Well C ctor Date
By signing this form,I hereby certifr that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or 1:3No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known Nell cawstrai taw information and expkaix Ike nature oldie 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-I is needed. Indicate TOTAL 13\}MBER of wells construction details. You may also anar h additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ( 7 S (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifAfferent(example-3@200'and 2@100') construction to the following;
10.Static water level below top of casing: 2 a (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iuieetion Wells: In addition to sending the form to the address in 24a
O T/�/L above,also submit one copy of this form within 30 days of completion of well
12.Weil /�
construction method: 4r/ ! s'Y 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: /� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) v Method of test: r&'h,9 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: L Amount: 2 -( pi 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