GW1--03140_Well Construction - GW1_20240522

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well ContractorT Information:
LstLn CPA"' 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
3D�y-A itKtt. ,6)0 ft. Grac1
NC Well Contractor Certification Number 2KJ" fr f ����^'
IS.OUTER CASING(for multi-cued wells)OR LINER(if ap licable)
Water Wizards Inc FROM TO QQ / .X
I DIAMETER �T�H L1HIICKNESSS MATERIAL
Co y Name 0 ft. ! ft. _ in. piiL
.-Ae /�/� ��j�(� lb.INNER CASING OR TIMING(geothermal closed-loop)
2.Well Construction Permit#: 0Ss'VI V4V --44/f-! FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft• ft. is
3.Well Use(check well use): ft. ft is
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipalPublic ft. ft. In.
Geothermal(Heating/Cooling Supply) �V Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) IS.GROUT
Irrigation FROM ( TO 1 MATERIAL i E.MPLACEMENTMETHOD/&AMOUNT
^'
Non-Water Supply Well: C ft. b 3 ft- 3 Ho/ pOf fle4 /0coth
Monitoring Recovery n fr. /00 ft. � !� loss
Injection Well: gag(
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 DStormwater Drainage ft. ft
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) PROM TO DESCRIPTION(color,hardness soil/rock type,grain size,etc.)
/ O fr. 7 ft. overt Mule,
4.Date Well(s)Completed: "-/1 -/e! Well ID# 1169 /! fr' 1 t)n. Cf,Gvip4
5a.WellLocation: LICft 28g ft_ &r: L rd � i._, ..
nn ry ,:
Facility/Owner Name /� Facility[Dr*(if applicable) ft' ft" MAX •r _
W333 Uj rq;1,1%4or of 4,40,-o /l c ft. n
Physical Address,City,211 Zip ft. ft
P (sO•l 21.REMARKS
County Parcel Identification No.(PIN) QCp1((N'sts'Ii'"— lik//
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Ce ' cad
36•‘13N/26(2 N - 7g• 90493i36 w 24 A9 4-!! -ZN
6.Is(are)the well(s)> Permanent or OTemporary Signs of Certifi ell n r 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: DYes or riao with l SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out knonw well construction information 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:
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: //A SUBMITTAL INSTRUCTIONS
Q
9.Total well depth below land surface: Z U� (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if Afferent(example-3@200'and 1@/00) construction to the following:
10.Static water level below top of casing: 2 S (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+"LL 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ID'? fin.) 24b.For latectioi Wells: In addition to sending the form to the address in 24a
12.Well construction method: 1.ao 7
Q _4 above,also submit one copy of this form within 30 days of completion of well
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) 7 f M Qethod of test: i�IOti y' 0M�) Ic.For Water Supply&Injection Wells: In addition to sending the form to
,J / �'t/ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: / 1 7►f Amount: U,[fI 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