GW1--03126_Well Construction - GW1_20240522

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cw^fL Cco IC 14.WATER ZONES
FROM TO DESCRIPTION
Well ContraLi ctor NameNa n t�
iti
<46 It. a9lo ft. 3o 47-PM
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if ap Beable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name O ft. /_ ? ft. / 'At in. 513 ,/2 i P )C
f (('� ] 16.INNER CASING OR TUBING(geothermal)closed-loop)
,
2.Well Construction Permit#: N 2-7'"0a O(`) FROM TO DIAMETER THI(KNESS _, MATERIAL
List all applicable well construction permits(i e.UIC,Counq'..S'tate. 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
Agricultural OMunicipaUPublic ft. ft. In.
Geothermal(Heating/Cooling Supply) 13cesidential Water Supply(single) ft rt. in.�
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 ft' G2 3 ft. 44( i,S 7c t 6S P rc
Monitoring Recovery ft. ft. t�Lty_✓� yd� n I^J�a�
Injection Well: ft. ft. t
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology ®Subsidence Control ft. ft.
Geothermal(Closed Loop) QTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DFSCRIF TION(color,hardness soil/rock type grain sire etc.)
ft. 0- ft- Over bc.t r J en
4.Date Well(s)Completed: y-30 1ay Well ID# e2 ff. 6.. ft. (2.e
Jr_si
a.Well Location: 35 366 ft. brie, 1 LI
Plec i,n4 G c...c-fr, WO ) ft. ft.
Facility/Oewner Name I, Facility1 ID#(if applicable) ft. ft.
co Sd1.4 t' .ic c I IJ r .li5 BOOfcx...9 L 1UC ft. ft. '� .:.�. '�...i i�r' ,._,_,
Physical Address,City,and Zip .9.1.27v ft. ft. MAY 2 '-r' '07 T
Or'G(ne ciY5(17as(,73 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3‘.Iya710 N -. 7c1 .09I )91)/ w
.f 416-7-7 r� ci-3U-.29
6.Is(are)the well(s) rmanent or Temporary Signature of Certified ell Contractor Date
By signing this form,1 hereby cenifl'that the weB(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or Ei<io with 15,4 NCAC 02C.0100 or 15A 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.
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 i GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
��y�
9.Total well depth below land surface: "! (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@/00') construction to the following:
10.Static water level below top of casing: «S (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1
II.Borehole diameter: 6 Vs( (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: A r , -'11[.,f"A/ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) l(
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: n 1 1636 Mail Service Center,Raleigh,NC 27699-1636
k3 13a.Yield(gpm) 3 S Method of test: 10C•-41 ,20 th./) 24c.For Water Supply&Injection Wells: In addition to sending the form to
a the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 14TH Amount: Q y oz. completion of well construction to the county health department of the county
where constructed.
Form G\V-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016