GW1--03836_Well Construction - GW1_20240628

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
) k-c tT L ^• ,4- ': Y 1d 14.WATER ZONES
Well Contractor Name OM T r DESCRIPTION
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a cable)
Water Wizards Inc FROM , TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. j/i it. ( in. )a-, 6i t�"le' ,
16.INNER CASING OR TUBING(geothermal closed-loop) `/ G�
Z.Well Construction Permit#: FROM TO i DIAMETER THICKNESS 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 in.
Water Supply Well: 17.SCREEN
FROM TO DAMETER SLOT SISZ THICKNESS MATERIAL
Agricultural 0Municipal/Public ft• ft. In.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) IS.GROUT
Irrigation FROM ' TO ' MATERIAL ' E. PLACEMENTME &AMOUNT�
Non-Water Supply Well: 0n• 1. W P~ rni.-✓`ge Jif hits
Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSatinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD _
Aquifer Test EStormwater Drainage ft. ft.
Experimental Technology DSubsidenee Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets If necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION Kolar,6ardaeas soiUrock type,gain sin etc.)
fL ft.
4.Date Well(s)Completed: I'�! 41/ �l Well ID# ft• ft• /^�
E „ •• •,1
Sa.,}�e0 Location: ft. �-0 L • `r t j
1j,- - ti✓p,:kce ,_
f� JUN 6 2024
ft.Facility/ow.,Name Facility lD#(if applicable)
t ‘I 7 I f.,� ♦ 0 1121 ft. ft. lati c.s.i;£n rs'rryAi. .1 Uset
Physical Address,City,and Zip ft• ft• rioN r sow
". t (er irk 21.REMARKSS�� ,�� ` �1y�,/� ,y���
County 1 r`(C1,, Parcel Identification No.(PIN) /•..�,re" ,1 t1' i 1 ii ICJ— 5,7"' :fr tern •4-sr
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: "^' `-'-e VV�- `
(if we 11 yfiield,one Iat/llong�is sufficient)
icient) 22.Certification: r / I
JLii !f"i.ac 7l N 97t ga504W r/,7 ,i4_�/N(tJ {0//V%V"
6.Is(are)the well(s) manent or Temporary Signature of Certified Well Contractorr/ - Date
By signing this form,I hereby certi&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: es or ONo with ISA NCAC 02C.0100 or ISA 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:
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 construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ‘V//''� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd(erent(example-3@200'and 2@i00) construction to 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: (in.) 24b.For Injection Weds: 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: ',el—VI 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) /6 Method of test: Y I`•$ 24c.For Water Supply&Injection Wells: In addition to sending the form to
l� , the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: � •4—14' Amount: ' '✓(1-��'r' completion of well construction to the county health department of the county
t where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016