GW1--03304_Well Construction - GW1_20240603

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contra
// a or Information:
I Ae vn 1/1 ''1Gill (en 1 14.WATER ZONES 1
Well Contractor Name FROM 1 TO t Irrrvan
27 /� 2c�;n. 2csf -,
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap limbic)
Water Wizards Inc FROM 0 DI ETER Tl/H)C NESSS, TE �L�
Company Name l/� ft. C n. in. J(1-1 `/" UjT IV 1
16.INNER CASING OR TUBING(geothermal closed-loop) M
2.Well Construction Permit#: FROM 'i O ` DIA. TER THICKNESS ?Tit.
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. ft. In -frjoff
3.Well Use(check well use): ft. ft In. a/"1 /f/
Water Supply Well: 17.SCREEN (J
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) ()Residential Water Supply(single) «. ft. in.
Industrial/Commercial DResidential Water Supply(shared)
11i.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft.
Monitoring ()Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ©Stormwater Drainage ft. ft
Experimental Technology ()Subsidence Control ft. ft.
Geothermal(Closed Loop) ()Tracer 20.DRILLING LOG(attach additional sheets if Necessary)
FROM TO DESCRIPTION(toYr,hardness,soil/rock type,grain sire,etc.)
Geothermal(Heating/Cooling Return) ❑Other(explain under 021 Remarks)
. rt. rt-
4.Date Well(s)Completed:3//?Ci)`/ Well ID# 1.-},LO I i q C ft. ft. 1'_ -
5a.Well Lo ' ft fL
a
ft. — JUN v Z024
6;r1g rc'wn,i,ell
Facili O Namel Faci ID#(if applicable) ft.
_0 ‘11
Je l
(J'�J /7f/=A 14/1/if��4�Plgy ft.ft. ft.
Ph al Address,City,and Zip ft. ft.
Kej f l� 31.REM / /
County Parcel Identification No.{PIN) kr'
/�� �� �1/��l l� �/1�� G '��/h.of
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 2 G f-/
(if well field,one lat/long is sufficient) 22.Ce l
N W 7M V " 7/V`ef?
6.Is(are)the well(s) ermanent or Temporary
SigtatureofCertifl C or 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: ErKes or [3No with I SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well ecwrtract ow information and explain the nature of the copy of this record has been provided to the well ouster.
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 I OW-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: z C G (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200''and 2@ 100) construction to the following:
10.Static water level below top of casing: ) (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use" " 1617 MS II Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (Y (in) 241).For Injection Wens: 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:4,7 it tl)40// construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY LLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of tend-_ p4/71) 24c.For Water Snooty&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: ` l/./7O Amount: � C fin, 1 completion of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016