GW1--03331_Well Construction - GW1_20240603

IPrint Form
WELL kNSTRUCTION RECORD (GW-1) For Internal Use Only:
1.W I Contractor Information:
i i Lti �,� , rCil 14.WATER ZONES
We1lContractorName FROM TO DESCRIPTION
y `� `�
/,�.1 G so o ft. 596 ft. (4 3
ft. rt.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if abk)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIALLY
6 ft. -O ft 1 In. 5 i 2/O P�,/1
Company Name
✓7vf2Nc
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Weil Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC Camay,State,Variance,etc.) t. Se ft. tn.
3.Well Use(check well use): ft' ft' 'a
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft, it. in.
DGeothermal(Heating/Cooling Supply) R idcntial Water Supply(single) ft. ft. ia.
Q Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
fl Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft ft. Pro , p„�_ro� /
°Monitoringecovery ft. ft / ter'" "`�
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable]
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIALEMPLACEMENT METHOD _
Aquifer Test fStormwater Drainage H. ft
Experimental Technology Subsidence Control ft. ft.
(isothermal(Closed Loop) Tracer 20.DRILLING LOG(attack additional sheets if necessary)
Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM ft TO DESCRIPTION(color,hardness soil rock type,gain size,etc.)
R.4.Date Well(s)Completed:OVC7qQ/A Well ID# ft- ft- i
Sa.Well Location: ft. ft
i- r►i.s ft ft. - -LI4 v c074
Facility/Owner/Named ^ Facility ID#(if applicable) ft ft
O' Ms.o' A ��/ fL ft •r .. ''P.
Physical Address,City,and Zip ft ft
D21.R'fE�MAR(S // l
County Parcel Identification No.(PIN) / X t"J��,,V�J r`� I I /�f B
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: `-e - r*° ...er—St'2_ 11
(if well field,one IaVlong is sufficient) 22.Ce
rtification:
sU09:
�f,° .-7I11, ,,r/e1 7T V 4;.(1 J g6Oyl"W 2
(J'�r� Signature of Certified Well Contractor Date
6.Is(are)the well(s)efenanent or r3Temporary
By signing this form.I hereby certii that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: or ONo with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Constriction 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:
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 r f1 (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 2@l00') construction t0 the following:
10.Static water level below top of casing: a (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: CI it (in.) 246.For Iniection Well,: In addition to sending the form to the address in 24a
12.Well construction method: K
a j-ll t Cci above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.c.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) t I Method of test: 10(/A• I 24c.For Water Supply&Iniection Wells: In addition to sending the form to
ff 4- 1 I/ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: I-) 14 Amount: ) 3 e t•—Qi completion of well construction to the county health department of the county
where constructed.
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016