GW1--03142_Well Construction - GW1_20240522

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contrac r Inforlmatioa:
Ctn/trl VV I,J'e p/✓) ce`') i 14.WATER ZONES I
Well Contractor Name OM TOOF.SCRIrT10N
NC Weil Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(If ap usable)
Water Wizards Inc FROM TOn TER THICKNESS MATERIAL
Cft. G2- ft• in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM J DI ER THICK. MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) G ft. r/ 3 ft. to , 4/C
3.Well Use(check well use): ft. 11 ft i�
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural 0M)tecipaUPublic ft. ft, in.
Geothermal(Heating/Cooling Supply) MAesidential Water Supply(single) ft. ft. in
IndustrialCommercial OResidential Water Supply(shared) 18.GROUT
irrigation FROM ' TO I MATE EMPLACEMENT METHOD& UNT
Non-Water Supply Well: �` ft. / /1? ft. A/ aiLff f i/r/ 2 lc S.
Monitoring OFtecovery ft. ft.
Injection Weil: ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Coo' Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil rock type,train sire,etc.)
-gyp ft. ft.
4.Date Well(s)Completed: 24,CI Vwel1 ID#A n -� ft.ft. ft
5a.Well Locates
�nG �.: ft IL .A)/ 2 U24
Faaycility/f wwoer Na Facili m#(if applicable) ft. ft.
-.,y.:.
icalp Address,C. ,and ip P, ft.
ft.
21.REMZ9',0c,
/ 1 County n Parcel Identification No.(PIN) l /s,,, - ' '�/4/ c' J/?
re4 f A_.r /L1 I/.--
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: G
(if well field,one lat./long is sufficient) 22.Certif n: . -ZCh-C \
N W Z�/-2aV
6.Is(are)the wells) Permanent or Temporary Signature of edWellrkci Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: es or 0No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this Ira repair,fill out known well cat rime-May in vcwatsw 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 OW-I is needed. Indicate TOTALNUMBER of wells aonstnuction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: VC (ft-) 24a. For AB Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@l00) construction to the following:
10.Static water level below top of casing: S (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: P in) 24b.For Infection Wells: In addition to sending the form to the address in 24a
":051C4//
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 SUPPL WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 0 Method of test: a'�i�' 24c.For Water Supply&Injection Wells: In addition to sending the form to
vvv theres above, also submit one copy of this form within 30 days otf
13b.Disinfection type: /t� .t`�C Amount: / (1 /7[ completion
adds ofes)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