GW1--03844_Well Construction - GW1_20240628

IPrint Form
WELL)NSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: n
664,�+_ �57'd,4Ate,1�'(U 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
(4 4 t���-c id,oweft-
ft H.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if• •able)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL/IA
Company Name
ft. 7U ft VI la. 'o gc e
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.UIC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): rt. ft. ra
17.SCREEN Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
['Agricultural ©Municipal/Public ft. ft, le.
Geothermal(Heating/Cooling Supply) ['Residential Water Supply(single) ft. la.
['Residential Water Supply(shared) IL GROUT
"Irrigation PROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0ft. 7o ft- ps o-4-' /le,[�, 'JPt,5
aMonitoring ['Recovery ft. ft.
Injection Weil:
ft. ft.
['Aquifer Recharge ['Groundwater Remediation
PACK(if applicable)
['Aquifer Storage and Recovery ['Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD _
['Aquifer Test ['Stormwater Drainage ft ft.
['Experimental Technology ['Subsidence Control it fi.
['Geothermal(Closed Loop) ['Tracer 20.DRILLING LOG(attach additional sheets If ae«asary)
['Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,rrma.rsr.olvr�k Type a.t.r se de.)
4.Date Well(s)Completed: ) e7�Oif Wel i1)# ft. ft. ; `4.`'A L. `Jf Q
ft. ft
5a.Well Location: 11)N 2
ri4 _ cc l,t�vt.%t f. ft. 8 2024
Faciilliicety//O�wnerr,-/,Name
� J { Facility+ iD#(if applicable) ft. ft IfnG:,'.a4.c��l rr��',^,tea,
Z0 1 J.1erii-. . '"�."W 7 q l0 ft n. v r,Ca St4
Physical// Address,City,
and Zip
ft ft.l�"Llae 21.REMMAAR'KS f,�����/� n /
County Parcel Identification No.(PIN) - ��o w "`f?A I i f C s' 1 QB
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: mr 0. C' WV
(if well field,one lat/long is sufficient) 22.Certification:
Co. I247y N�-7'V/1l'' 4d6 W 2 /�7/a
6.Is(are)the well(s)DP#�rmaaent or ['Temporary sign ed We Contractor Date
By signing this form,l hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: d or ['No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out brown web construction information and explain the nature of the cam'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: //``ll SUBMITTAL INSTRUCTIONS
G�V 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 if different(examp e! 3@200'and 2(a))I00) construction to the following:
10.Static water level below top of casing: V-V (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: (,/-C4 (in.) 24b.For Infection 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: 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) 1.() Method of test: 24c.For Water Sunnlv&Infection 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: '� 7L L4 Amount: e V2-te ) completion of well construction to the county health department of the county
where constructed.
Form O W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016