GW1--03137_Well Construction - GW1_20240522

Print Form m J
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Na
Contractor Information:
6 ""-- - t7\V (� 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
W
(,l g Sal'-c qo fl. G f. 'UsP4n
ft. It
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Wizards Inc FROM TO DIAMETER THIIyC�KN/fES, �VS MATERIAL�
Company Name ft �Q [I/ �
i� ��"l` 0 c
lb.INNER CASING OR TIURING(geothermal closed-loop)
2.Well Construction Permit#: FROM ' TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft- R. in
3.Well Use(check well use): ft h iB
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft, rt. In.
Geothermal(Heating/Cooling Supply) DiKidential Water Supply(single) ft ft. in.
Industrial/Commercial Residential Water Supply(shared) Is.GROUT
Irrigation FROM ' TO ' MATERIAL EM ACEMENT METHOD&AMOUNT
Non-Water Supply Well: U ft. cr0 ft a.. u # C u / / l l
a /&5
Monitoring R very ft. ft ( �B'� I'G{
Injection Weil:
ft. ft.
Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery r3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage H. H.
Experimental Technology DSubsidence Control ft. ft
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
( g� g ❑r(/'Well
(explainn Uri
#22IwReemarks) n �
4.Date Well(s)Completed: "//r2 j�( Well no ' i 1 yr"1 ft- ft- .
5a.Well Location: ft. ft
k 9 �(r te�_ 4,4-c '2,ft. ft MAY 2 7O?4
Facility/Owner N e Facility!Mt(if applicable) h• ft.
69) S-►.� 6 �2 ft. ft.
Physical Address,City,and Zip ft. ft. i ,.i.,.7,'_
P501A 21.REMARKS
2e t
County Parcel Identification No.(PIN) w � (!/� �L/>�' 1�Nq:C1Wr`J
L
Sb.Latitude and longitude in degrees/minutes seconds or decimal degrees: I
(if well field,one lalllong is sufficient) 22.Certification:
•(-13c100--q N 'MO(34.5 W
6.Is(are)the well(s) rmanent or Temporary S�na of/ 11 onuaccor ate
By signing this form,1 hereby certf that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 'Kes or ONo with 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this era repair,fill out known well construction arfor ation 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:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 its needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 41 / (IL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd(erent(example-3@200'and 1@100') construction to the following:
10.Static water level below top of casing: 9- C (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+�j 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: V 'i (in.) 24b.For Injection Welts: hr 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:
(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) I a Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
f, 1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: T 1-4 Amount: completion of well construction to the county health department of the county
where constructed.
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016