GW1--03300_Well Construction - GW1_20240603

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only.
1. ell Contra or Information:
/t'6'4 4 IA/ ) 'I 1 t611/y) (L/) 14.WATER ZONES
Well Contractor Name 1 Mom TO DESCRIPTION
it. ft r�/1// fit.C fir ✓I
l�� 73 a• left. mel /1 `2.,i—le -l�reel
NC Well Contractor Certification Number 15.OUTER CASING(for mold-cased wells)OR LINER(lisp )
Water Wizards Inc FROM ft. T DIA ETER THICK MA
Company Name 0 ft , in- St r liC i
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: I FROM/ T DIAMER THI K.NESS_ M A
Liu all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) � ft r
• in. i-2bC3.Well Use(check well use): '/ h• to . in.
1Water Supply Well: R F SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) R (r, in.
Industrial/Commercial Residential Water Supply(shared) IS.GROUT
+ Irrigation oy. t TO r MATE 1SfPLACEMENT METHOD&411tOUNT
Non-Water Supply Well: V`( R' (/ D' P l I
,/ 2 r� l!/L.)
( Gj
°Monitoring °Recovery ft. ft.
Injection Well: ft. R
Aquifer Recharge DGrotmdwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery
Aquifer Test
°Salmlty Barrier TO MATERIAL I MPLACEM ENT METHOD
DStormwater Drainage ft. ft.
Experimental Technology °Subsidence Control ft. TO
Geothermal(Closed Loop) DTtacer 20.DRILLING LOG(attack additional sheets if necessary)
°Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardpan,aeiVrock type,grain sloe ere.)
/�p ft. ft.
4.Date Well(s)Completed: Well UMf 1 p 3 1 1 01 n• ft.
5a. ell Loca n: ft. ft. .w-. k.. . , i; }
l7,-(41 ( �' it P ) ftliiti 1 ft. ft v _ 2024
Facility/Owner NaZ(:4,,4fl
/ Facility m#(lt applkable)
j1 ) :ten y i . , . .,,-
r
teal Address,City,and Zip
n ft. L•;.t.„"_
, S tin 21. MARKS �/�J if7 / 16/4'/2
Cormty Parcel Identification No.(PIN) ��// "/` t` h O�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: /l! 7&>� 1/`1, "" //
(if well field,one lat/long is sufficient) 22.Ce • do j/ m
N WE� ' LL
6.Is(are)the well(s) Permanent or °Temporary rgna ertified+Well( p6 Date
By signing this form,I hereby certifi,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or °No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out knomw mall conrtrartiaa iafarmatia, wad explain the aatxre 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 I a SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: it `' (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 2Qa 100) construction to the following:
10.Static water level below top of casing: 3 0 (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: (hi) 24b.For Injection Wells: In 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: iZiT ��/WI 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) Method of test: f U!/it Q,) 24c.For Water Supply&Injection Wells: In addition to sending the form to
I��JJ VV the address(cs) above, also submit one copy of this form within 30 days of
13b.Dislafection type: /(71 f Amount: 2.- (//�__ __ completion of well construction to the county health department of the county
r where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016