GW1--03130_Well Construction - GW1_20240522

Print Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contra or Information:
//icie 7 'd/Jj/ ,4.J,<'ir 14.WATERZONES
I ""�"iiidOM
/ ft. D 3RIPTION
Well Contractor Name (',
<� 4 rcut.ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LiNER(If ap licable)
Water Wizards Inc FRO TTO DIAMETER THI NESS MATERIAA
ft. 7 ft. m. C (7 9c/ y(-
Company Name _ ��"11 !/
1, W�"1� 16.INNER CASING OR TUBIN (aeotbermal closed-loop)
2.Well Construction Permit#• lti Z_1 °O FRO TO TrO, DI�/METER 1HICj�NESS MATERIAL
List all applicable well construction permits(i.e.U1C,County.State.Variance,etc.) / /' ft. x0 ft. l L in. / ��/ y1 J/
3.Well Use(check well use): l/ H' `J k' 7 _1O' (-i/7 �f r/f f�
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIALAgricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) ga<sidential Water Supply(single) ft. ft in..—
[J Industrial/Commercial DResidential Water Supply(shared) i8.GROUT
nIrrigation FROM TO MAATTE77 /EEMPLACEMENT EE erNT
Non-Water Supply Well: ft. 0ft. /� ✓✓JJJJL,,,11// 4/.... J
ce
Monitoring Recovery ft. ft. r
Injection Well: — -
ft. ft.
ElAquifer Recharge Groundwater 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 QSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer
Geothermal20.DRILLING LOG(attach additional sheets if necessary)
(Heating/Cooling Return) QOther(explain under#21 Remarks) FROM ft. TO
H. DESCRIPTION(color,hardness,soil/rock tspe,grain sire,etc.)
4.Date Well(s)Completed: � 2 Well iD# ft. ft.
(.... .-
5a.Well Location: ft. ft. . .` . '.:t....i •• • .
I.
110,11,4 PI /Y,'� ( ft. ft. MAY 2 "c�2t1
Facility/OwnerFFa/ / Name /�/`� /// Faciill/iitt/y}D#(if
/applicable)//I�// I1 ft' tt•
U q 4,,,, (7.t.-lam (/'1 /e- (•/ ip/ /$1, !/ H. ft.
Physical Address,City,and Zip J ft. ft.
County i Parcel Identification No.(PIN) 7/
t p ili
/ e!I- ///k , i, i ii-P 7II4L/1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 41l Cr art' J
(if well field,one latllong is sufficient) 22. er' cation:
N W 7--2c2
6.Is(are)the well(s) Permanent or Temporary ignature o cni5cd ell o Date
By signing this form,1 hereby certify that the we/l(s)was(were)constructed in accordance
7.is this a repair to an existing well: LQ 's or DNo with 15A NCAC 02C.0100 or 1SA 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 hack 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
9.Total well depth below land surface: y6 (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@n00'and 2@100') construction to the following:
10.Static water level below top of casing: `O (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 Infection Wells: In addition to sending the form to the address in 24a
fro, / above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: /
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) Method of test:fn i.1/f/ 24c.For Water Supply&Iniection 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: /Z7 Amount: 3 a/,)/ completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016