GW1--03132_Well Construction - GW1_20240522

IPrint Form J
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
J0) 1 14.WATER ZONES
Well Contractor Name PROM TO DESCRIPTION
3024/ -/4- 3($ft 310 5 'i1
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if a cable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MAIERIAL
Company Name 0 fft. /`f D 1 in �G„�D /�C
2.Well Construction Permit#: DSy�DQ 7 16.INNER CASING OR TUBING(geothermal closed-loop)
�(/ 7 7/ -�2� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County.State,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 MATF.RIAI.
DAgricultural Q icipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in.
0Industrial/Commercial OResidential Water Supply(shared) lg GROUT
11Irrigation FROM TO MATERIAL EMPLACEMENT/ METHOD&AMOUNT
Non-Water Supply Well: 0 ft-
103" ft- 3 / r/1vf/ ,/ "Oar: / - �/�j
Monitoring Recovery ft• ft" l �7
Injection Well: D GG T tr�c s u^r poi cfd zQQ/JS
Aquifer Recharge Groundwater Remediation ft ft.
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �Stormwater Drainage ft. ft-
Experimental Technology 0 Subsidence Control N. ft
Geothermal(Closed Loop) Tracer 29.DRILLING LOG(attach additional sheets if rta�ary)
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,burdens,soiurock type,pain she,etc.)
( g/ g + ,❑/)Other(explain under#21 Remarks) O E
4.Date Well(s)Completed:J `7 Well ID# fr7(/37 7 f 5 7 R- cit.i��'=`�C:�
5a.W
ell Location: ,
.37 R• LD - f't� et„A ; .-
/ Id/01.1.1n^c -ici5/A-Ji ft ft. ty.-. .:..I V 1 ..;.
Facility/Owner Name Facility ID#(if applicable) h' H' MAY I AY 2, '2 ?fi?A
564My A/r,-IS I //e idx ir-� 46 ft. ft. JI T
Z7s 7/ - • Y.
Physical Address,City,and Zip L � ft. !(�`.��•' ' �'• �1•�;' �' '
nSon 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)
1� 2 - ,p 22.Ce on:
3(,'3-///�3 N 71?��. 8J5&1c W
6.Is(are)the well(s) rmanent or EiTemporary 8m of ed We aua Date
� By signing this form,1 hereby certify that the%ell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or Ulf with ISA NCAC 02C.0100 or ISA 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
9.Total well depth below land surface: CO (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 a 200'and 2@l00) construction to the following:
10.Static water level below top of casing: 2c (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+/ �Q 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (!/ O (In.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: as
D 7G�r(� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: tg
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
e
13a.Yield(gpm) Method of test:j3/( r-'* 24c.For Water Suooly&Injection Wells: In addition to sending the form to
r'
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: i/f/I' Amount: /gevir.L t.> completion of well construction to the county health department of the county
where constructed.
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016