GW1--03129_Well Construction - GW1_20240522

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1,Well Contra or Information
t
l�nI ern VI I /GM<C7 14.WATER ZONES
Well Contractor N e FRO TO DESCRIPTION
7q 7 ft. 7.S�ft. n)
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap Hcable)
Water Wizards Inc FROOMJ (T/Oj�//�� DIA7/yETER �T✓HIC LESS /M�Aj , //
Company Name V H. o fr• (-., m• (-,4 ` "/a 1 i
w��``,��� 16.INNER CA$TNG OR TIMING(geothermal sop)
2.Well Construction Permit#: W Tp DIA)M�fTER THl KN SS
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft.
/n ft
(�/ tR G �/ I/
3.Well Use(check well use): IL/ ft
/// t� 7l PTERIALC
V
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural D lcipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared)
M.GROUT � 1
Irrigation FROM TO 1 MATE EMPLACEME METHOD&,y$ T
Non-Water Supply Well: 0 fr. /7 1 ft- fer/ � 1 , /r2 5d /
Monitoring Recovery ft. ft.
injection Well:
ft. ft.
Aquifer Recharge oGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test (jStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) o TO DESCRIPTION color, so rock in size,etc.
4.Date Welks)Completed: 1'7 17 28Wen ID# f. ft.
ft. ft.
Sa,Well Location ,.;... ,•-i,. r t- C.
,/q01 `n /psi/I (0/7 ft. ft. MAY p�/
Facility/ownerName Facility 1D#(if applicable) ft. ft. M A I 2 u (G
cc,,,y,, ,,
Physical Address,City,and ap
ft. ft. :I 1' 4 .. J i�i
V/GM e �/
County Parcel Identification No.(PIN) piqfpi„k 1(�" aleevlici/ l� u( /1 ,r�
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: !/ 'S � /
(if well field,one lat/long is sufficient) 22. •y• *•do
N W c ?-2 ZZ y
6.Is(are)the well(s) Permanent or DTe porary signature o Certi6 c Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: es or �No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this it a repair,full out known well constreeeMas information and explain the nature ofthe 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)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: I/V C (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@l00') construction to the following:
10.Static water level below top of casing: J 6 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+jj 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (Q (in.) 24b.For Intention 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: ie 0// construction to the following:
(i.e.auger,rotary,cable,direct push,etc.5555 /
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: 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: C. P Amount: ((/ r 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