GW1--03139_Well Construction - GW1_20240522

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
t I-, L 64)10 L I 14.WATER ZONES
FROM I TO DESCRIPTION
Well Contractor Name
�s77 A tire) ft. yll. 3 &PM
�90' .ys`R- 1 &P M
NC Well Contractor Certification Number
IS.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
►
Company Name o ft. (v 3 rt. (v Y<< to. S D R..dal I r V✓
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:J1 )%Jnvr)vo0 3 -a o?-/ FROM r TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,Counry,State,Variance,etc) ft• R. in.
Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft, ft. in.
Geothermal(Heating/Cooling Supply) isXesidential Water Supply(single) ft• ft. in.
Industrial/Commercial DResidential Water Supply(shared)
1&GROUT •
Irrigation FROM ' TO t ,MATERIAL r EMPLACEMENT METHOD&AMOUNT
NOD-Water Supply Well: 3 `-�
PP Y �! � !!v 3 ft ���!'IlS {"GYarea +' u 4'/1 Pk C.e
Monitoring ®Recovery ft. ft.
Ffv Lbs
Injection Weil: ft. ft.
Aquifer Recharge oGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
j(� y 1 0 ft. 3 ft C7ttE�'1 u-� t1 o
l
4.Date Well(s)Completed: i- -1 !''..2 C1 Well ID# 113-1 I S 3 ft- `'+ir ft. Rea C tit
S//a��Well Locat{i�on: LI V 3vo ft. 6rr'ei 2 CC - 1.-
ft. ft.
inJa
Facility/Owner Name Facility(DI((if applicable) ft. ft A ,� 2 G ` 2�
.,2 I v,.4o;;4 LA ac id:yro NG , 7s7`1ft �,'i.
Physical Address,City,and Zip ft. ft. ,`.
P 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) 22.Certification:
3G.,373 s7ty N 1q.019V115 W 416-770 41-/ 9-aq
6.Is(are)the well(s) rmanent or Temporary Signature of Certified well ontractor 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: 0Yes or !Frio with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out knonn Nell eanstraa^tiav information and explain the nature ofthe 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 GW-1 is needed. Indicate T(7TAL NUMBER of wells cnnstnution details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3Cx, (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@200'and 2@100') construction to the following:
10.Static water level below top of casing: a (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i •
11.Borehole diameter: £P /9' fin.) 24b.For injection Wells: In addition to sending the form to the address in 24a
a.,:, � above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: )rconstruction 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 Method of test:s p� 1 ca, ,Ai.11 24c.For Water Supply&Injection Wells: In addition to sending the form to
L/ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: k c if if Amount: C?Z. 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