GW1--03134_Well Construction - GW1_20240522

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
/'l,�r l O 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
30)-Y A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for mold-eased wells)OR LINER(If ap licable)
Water Wizards Inc FROM TO DIAMETER DIAMETER THICKNESS`1 MATERIAL
Pik-
Company Name 0 ft r 00 f` q in Cf(;t. N0 Pik-
05w/ad79 1—� lb.INNER CASING ORTUBIAMETE(geothermal closed-loop)
2.Well Construction Permit#: FROM ' TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, ariance,etc.) fr• H. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public it. ft. in.
Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) '
fr. f4 in.
Industrial/Commercial ErResidential Water Supply(shared) IS.GROUT
Irrigation FROM(� TO MATERIAL ' EMPLACEM METHOD&AMOUNTS/Non-Water Supply Well: D ft' ( 3 1t 3f t�lIi9/G p ii^ t o-'/ jr-(f�s
Monitoring ®Recovery ft 1 R /) j.
Injection Well: t70 / /LC./ CC�`�e- �Ot�✓C� Sr
ft. ft.
Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft ft
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO D CRIPTI N(color,jpardness,soiVrock type,grain size,Nt.)
Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0 ft 7 ft- v(ibi - Cr1
4.Date Well(s)Completed: ti S I211 Well ID# i_ell7 ft. 3 I ft- Id.t(
3 ( ft. 3 LI9L c, r t tDe.N
Sa.Well Location: - . ,.
5 ; ark 5 T tiro h/6�e/><'� ft. it rM ; . I
FaCility/Ow6er Name Facility 1D#(if applicable) ft. ft. L O
t o ss -fro,,-1 702 l74, l _�v.--efor Ay olv fr. It MAY 2 eJ
Physic I Address,City,and Zip `% ft.' "-
11C r.V/, 21.REMARKS a l'*'`.. -
County Parcel Identification No.(PIN) t��yly���/I Wed Cif 'IV be l✓I0°C-
7Z )( 4kvo c •Prot .,�. C 1��1( .
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: `'� � S
(if well field,one lat/long is sufficient) 22.Certification:
3( 107 y 7 N - 7&.ef1IIc1 w I^ 3_2y.C1 ci g `f
6.Is(are)the well(s)12ermanent or OTemporary Signs re of Certified Well on tor Date
By signing this form,I hereby certifr that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair.,Jul ore!known Hell cacrt/n- ow information and explain She 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 hack of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOT AL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: (� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3-(O (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(fdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 1-‘ (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: ,D (in.) 24b.For injection Wens: In addition to sending the form to the address in 24a
12.Well construction method:
0 tof,i(ti above,also submit one copy of this form within 30 days of completion of well
(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
13a.Yield(gpm) _ Method of test: 2 e
�la.J•r� e7iyy,44c.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: P i T� Amount: /y Dort t7 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