GW1--03133_Well Construction - GW1_20240522

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
,i J l- - e)/eXe,i 14.WATER ZONES
Well Contractor Name
FROM TO DESCRIPTION
30 -r"�4 L(ft. qc v�
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells OR LINER(if a Ruble)
Water Wizards Inc FROM TO DIAMETER THICKNESS►KJ MATERIAL`
Company Name D ft 'V� >t („kj in- (I/K- 1 f ifC�
WINNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State.Variance.etc.) ft ft. io.
3.Well Use(check well use): ft ra
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
QAgricultural DMunicipaVPublic ft, ft. In.
DGeothermal(Heating/Cooling Supply) 0(esidential Water Supply(single) ft. ft. in.
QIndustria1ICommercial DResidential Water Supply(shared) IS.GROUT
)hrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft-
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStonnwater Drainage ft.
ft
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) O Tracer 2L DRILLING LOG(attach additional sheets if necessary)
QGeotherma►(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color, saiVrosk type,grainetc)
�f / ,? tl ha Cq- roc
4.Date Well �3 /s)Completed: Well ID# / / �/n` ft. ft.
5a.Well Location: ((! ft ft.
/j'J (.ovt)-rcc f: LLC ft ft.
2 -iJ?I
Facility/Owner Name Facility ID#(if applicable) ft, ft,
5�37O AA-Ase /e/d /1 C ft. ft
Physical Address,City,and Zip Z 75 7 q ft. ft
Pei.$pn 21.REMARKS`
County Parcel Identification No.(PIN) /I/fd (J(!`
aC t Cf_- J1 o 57 f e
5b.Latitude and longitude in minutes/seconds or decimal degrees: 4- e /CC !y7 rGd�/�C' LLQ.. l
fees/ h
(if well field,one latflong is sufficient) 22.Cer).: n
s6._,„ 7,0 N '-7J I�31 S� W 'I// U�I/ •41/.9 3 i 3-2-'
6.Is(are)the well(s) rmaaent or Temporary 'ulna of Certified Well C or Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: I.�`e3 or DNo with ISA NCAC 02C.0100 or 1 SA 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 hat 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-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: (fL) 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@I00') construction to the following:
10.Static water level below top of casing: (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 Iniection 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: d �`� 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 teat:$/rl14/rl 13.-- '414c.For Water Smutty&Iniection Wells: In addition to sending the form to
/,/ J the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: ir!/ill.
/ Amount: Tj/O, u e el> 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