GW1--03330_Well Construction - GW1_20240603

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
1 (o/ 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor cam(/�t ontractor Name ('
-1 H (- - `� )ft. �V�
lC
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. Co ft. L in. SO Q,,,QC PVC-
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER__ THICKNESS _ MATERIAL
List all applicable well construction permits(i.e.U/C,County,State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. im
Well: 17.SCREEN
Water Supply
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural pM icipaUPublic ft. ft. In.
Geothermal(Heating/Cooling Supply) Mesidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) iS.GROUT
Irrigation / FROM TO MATERIAL EMPLACEMENT METH D&AMOUNT
Non-Water Supply Well: / f) ft. 6.0 IL PlJ'f-� IC Pa � i Ql k>
Monitoring Ir jRecovery �/ ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge JGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPI.ACLMEN r METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
Geothermal(Heating/Cooling Return)/ Other(explain under#21 Remarks) ft ft.
4.Date Well(s)Completed:-7//`14 + Well iI)# ft. ft.
ft. rt.5a.Well Location::f
15 C . F'r f lak �ti..=et ft. ft.
Facility/Owner Name `� Facility iD#(if applicable) ft. ft. .. Z¢
Physical Address,City,and Zip ft. R.
0 r I-CIO-
21.REMARKS
County V r� Parcel Identification No.(PIN) b4N"1I`t1 c— 1:1 I,zl .Co(' I'"
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1)---6----; n
(if well field,one tat/long is sufficient) 22.Certification:
c
(. a a-1( 1/N ( uo :?3/7 W i4- " < - a
6.Is(are)the well(s) nanent or Temporary Signature of Certified Well Contractor 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: s or ONo with i5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known 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:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths Ifdifferent(example-3().200'and 1G100) construction to the following:
10.Static water level below top of casing: CJ-h/ (ft.) Division of Water Resources,information Processing Unit,
If water level is above casing,use"41- 1617 Mail Service Center,Raleigh,NC 27699-1617
"11.Borehole diameter: I (in.) 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: '0� I' 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) 16 Method of test: f)(n-Y�I 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: IT 4 II- Amount: I(,Oj•K//2 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