GW1--03824_Well Construction - GW1_20240628

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1, ell Contract Information:
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iA/l G� tVir/ I j ��// ! 1 14.WATER ZONES
Well Contractor Name t FROM TO nEsc ntrTtoN
27c� 7 f g�
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Wizards Inc FROMROf TO DIAMETER TH S MA RI
Company Name 0 n. 76 f<- 0 in. ash PV (g(U
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM T DIAMETER THl s M(t,'c
RIAL
List all applicable well construction permits(i.e.(BC,County,State,Variance,etc.) 0 ft. G ft- // in- f
3.Well Use(check well use): lid in. 1
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
[]Agricultural a icipal/Public ft. ft. in.
OGeothertnal(Heating/Cooling Supply) Residential Water Supply(single) ft ft- is
❑Industrial/Commercial QResidential Water Supply(shared) is.GROUT
Irrigation FROM ' TO 1 MATERIAL ' CEMENT METHOD.&Ayr!
Non-Water Supply Well: rt SO ft. — 0 50 Ayr!
®Monitoring ()Recovery ft. V R.
Injection Well: —)
ft. ft.
Aquifer Recharge Groundwater Remediation —
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and RecoveryO Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD —
Aquifer Test OStormwater Drainage ft- ft-
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) ()Tracer20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiUrock type,grain siee,etc.)
OGeothertnal(Heating/Coolin Return) Other(explain under#21 Remarks)) rt. tt
4.Date Well(s)Completed: 'LZ'Z Well ID# .. ft �►�#l 7 11/
sa Well ties.: ft.
n JLlN 8 2023
r'r.GYiiiol'1 �f
F ility/Owner Name Facility ID#(if applicable) ft. ft. Inienunisa/*mousing Usit
Cal_c (-kne ii ft. ft. .,......
Ph 1 Address,City,and Zip
ft. ft.
ga m (.,
Z
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County Parcel Identification No.(PIN) t J r 510
o 1ri
�` r� trSb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: , ` ,77`
(if well field,one lat/long is sufficient) 22.Ce don'
N W 6 _ /2-22/-/
6.Is(are)the well(s) Permanent or QTemporary Signature of ed Well Co o Date
By signing this form,i hereby certify that the well(s)was(were)constructed in accordance
7-Is this a repair to an existing well: Yes or DNo with 15A NCAC 02C.0100 or i5A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out knower orll construction def venation 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-1 is needed. Indicate TOTAL NUMBER of wells coasttttr_ti,on details' You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I Z G (IL) 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'annt2@100') construction to the following:
0 10.Static water level below top of casing: - 2 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use" ' 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: /(in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
7a L � above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 0 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPL WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: i(/f/'I'Ir 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: Amount:_2_ / Uf S completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016