GW1--03837_Well Construction - GW1_20240628

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contr tor Infor�maation:
13IDh n NV),I/f 0 I/I1 cret 1 14.WATER ZONES
Well Contractor Name OM TO I nP tmON
22 q 6 �9 9s: cc : 11
/171
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(If applicable)
Water Wizards Inc FROM ft. ft.
D1A.yETER to I IESS I MATERIAL /
Company Name 0 Jr f/-) I ,at
16.INNER CASING OR TUBING(geothermal closed-1 p)
TA
Li Well ConstructioncablewelPermit#: ) FROM ft. Z C ft. D'L7 1 c_ VSC 7Z7C
List all applicable well construction permtis(ie.UIC,County,State,Varranc•e,etc. /""/ ` ta" ! —
3.Well Use(check well use): V ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
Agricultural D tcipal/Public R. ft. In.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. fL in.
Industrial/Commercial Residential Water Supply(shared)
1&GROUT
Irrigation M TO s EMPLACEMENT MATE I L PLACEMENT METHOD&AMQUNT
Y
Non-Water Supply Well: °ft. 0 ft. d1� 1vl/- ZGt 16 r
Monitoring DRecovery
Injection Well: R. R.
Aquifer Recharge QGroundwater 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-
ft.Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional
sheets if necesary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
r_ ft. ft.
4.Date Well(s)Completed:( 424 9 Well 1D# ft. ft' i'.. , '~ k R
Sa Wei Lora ft. ft.
°�f1 Zi ft. ft. JUN 9 8 2024
�JlA � ` vei,g
Facility/Owner Name Facility ID#(if applicable) ft ft.
Incur•,tµµ�e i3 r"s'nr '�-9 um
l ace/Li; ft. ft. Dili c, tom;
1 Z�/ �t
Ph teal A City,and Zip ft ft.
//t� /I'l 21.RE ARKS _I ^P / /jD T / /O
County Parcel Identification No.(PIN) CP �m( `i' ,/ / � TJ (r/ s/L��C
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 5ag�� ® 77 .Pr psi/ '7�- 'e �P r/
(if well field,one Lai/long is sufficient) 22• lion:
N W
6.Is(are)the well(s) ermanent or Temporary Signs We o 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 es or �No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this/r a repair,fill out known well canto-met/aw 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 Mails. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 6 Z (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@t2000'and 2@IOff) construction to the following:
10.Static water level below top of casing: / 5 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use' 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: (• y -, 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: COOf / 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) f Method of test: ii IA/I'7/) 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: 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