GW1--03301_Well Construction - GW1_20240603

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
r ('� C- / / 14.WATER ZONES
Wen Contractor Name Jam`' FROM TO DESCRIPTION
ft. ft.
y6-77 Aft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for mufti-eased wells)OR LINER(if a le)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
Company b ft. 623 ft- 4'Y.4 in- GDR a 1 ()VG.
16.INNER CASING OR TUBING(geotherm)closed-loop)
2.Well Construction Permit#: FROM 1 TO ' DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. 1O
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ftt, ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) Is.GROUT
Irrigation FROM I TO I MATERIAL r EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 4Q3 ft- f ?j -e - �L4v
Monitoring ()Recovery ft, ft. in
pl.“-ea
CoSih 'b_S
Injection Well:
ft. ft.
Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft' ft'
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach addidoaal sheets if Necessary)
Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sail/rock type,grain size etc.)
I �j tJ Q ft. .3 ft- Cvukz.r; n
4.Date Wells)Completed: 3- LI-e2 9 Well ID# A L -7 19 - 3 ft' 5'3 ft' Sanci
5a.Well Location: 53 ft' 3ao ft- 6anc1 S�or.e
ft. ft.
)rt/cAn La - . .
Facilityk caner Name Facility ID#(if applicable) ft. ft.
r ,
a-)S.
4 .
Physical Address,City,and Zip C.- of 7s� ftft. ft. uLM. ft •- Gc 4
Pt�- 21.REMARKS lr.`- .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fat/long is sufficient) 22.Certification: /�
3i0.N5y s 13o N -7E 000493C W _g3'770 3-14-1-RLI
6.Is(are)the well(s)DPermanent or Temporary Signature of Certified ontractor Date
By signing this form,I hereby certifr that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or ONo with 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this it a repair,fill out known well construction imfmamtiow and explain tke 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: c J (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifAfferent(example-3@200'and 1@l00') construction to the following:
10.Static water level below top of casing: t: 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: t.[+ hi' (in.) 24b.For Injection Wens: In addition to sending the form to the address in 24a
/� [) Y above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: A;r ICC 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: pp�� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) "7 Method of test:R1o4:t'1 c) ft');/l 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: NT14 Amount: I 49Z completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016