GW1--03135_Well Construction - GW1_20240522

1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
c/tJI e jki-e/y-N 14.WATER ZONES
F17...7. I T. i TIESCR[Vt'trlN
Well Contractor Name
2�-A 05n ft. ioc c&6M i
NC Well Contractor Certification Number / 2ft. /�©� S cP, /
IC-OUTER CASING(for multi-cased wells)OR LINER(if a )
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
ft. ft in. 5t-.i1 cr4 pet
Company Name �//� 1 _�///fir/�'3 ]�yNNER CASING OR TUBDI IG(geothermal closed-loop)
2-Well Construction Permit#: 0-s�')1 I OOI oO 2,0 EOM TO DIA METER 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 MATERIALAgricultural act cipaVPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) IlVesidential Water Supply(single) ft. ft. in. '
Industrial/Commercial a Residential Water Supply(shared)
1&GROUT
I Irrigation I FROM ' TO t MATERIAL,f1 t EMPLACEMENT IETHOO&AMOUM�' /1
Non-Water Supply Well: 0 ft. 6 fL 3/61)/'e0/c '/t I(,('�t, / r4s
Monitoring Recovery ft, r1(� ft. � 44-c 7 o gA s-f_(I 400/be5
Injection Well: ft '7 1
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM , TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage ( ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTrae,er 20.DRILLING LOG(attack additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,,oiVrock type,grain size,etc.)
Geothermal(Heating/Cooling Return)) flOther(explain under#2I Remarks) d ft. 7 ft-
Dverrh',-�r-1
4.Date Weill's)Completed:fig.2- Well ID# 4,57/24 7irt (-i f (44.1 /J
5a.Well Location: 57 / Cfrcif KQ(XL
Kf)(,bL1 iK_ ft. ft. U -•
�.-
Facility/Owne Namc Facility tD#(if livable) ft- ft. .1...i ` 1--• '
e
blOC) /-ILttvla Vocal Gl, �A ft ft�
-to(evilMAY 2 b 2021
Physical� Address,City,and Zip ,/G I
/�/ t i 21.REMARKS ,.-,.%g -y ?.
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
-
(if well field,one far/long is sufficient) 22.Certificatio :
3'.26-6 7,/3 N -7g,$s733q W G 1 , �ou-1 s.s--2orti
6.Is(are)the well(s) Permanent or Temporary of Cettrfied Well Con or Date
By signing this form.1 hereby cert�that the well(s)was(were)constructed in accordance
7.Ia this a repair to an existing well: ayes or o with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,/Ili owl brow well ecwrtrwetiar iryfa••mwlicw and explain Ike nature oldie 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 1 MN-1 is needed. IndicateTLfTAL13UMBER of wells Coostrtictinadetails. You may also artra•h additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
S.I mat wed tiepin omumtams sunace: //0 0 ltl-) 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'aand 2®100') construction to the following:
10.Static water level below top of casing: !/7 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,useJJ"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (9 .7 lin.) 24b.For Iniection Wells: 1n 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: �� `� 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) rD Method of test: /,nn tfOA>►'s �Iv, 124c.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: y (It Amount: b(re fs t-e`s completion of welt construction to the county health department of the county
where constructed.