GW1--03847_Well Construction - GW1_20240628

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: ~�
1.Well Contractor Information:
it(in / sa2 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
::% ft. ft.
Liu c /t J
NC Well Contractor Certification Number IS.OUTER CASING(for m ells)OR LINER(If ap licable)
Water Wizards Inc FROM TO [DIAMETER THICKNESS MATERIAL Company Name v- IL
a e)D. I im 57HI�l 616 pL,L,
lb.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.VIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
PROM TO DIAMETER SLOT SIZE THICKNESS MATE RIALAgricultural 0MunicipalPublic it ft. I..
Geothermal(Heating/Cooling Supply) Q$.estdential Water Supply(single) ft ft to
Industrial/Commercial DResidential Water Supply(shared) lei.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT ETHOD&AMOHIST
Non-Water Supply Well: U ft. 40 ft* IOWlU� �/ &6�U
Monitoring D Recovery ft. ft.
Injection Well: ft ft.
Aquifer Recharge D Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL ' EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft ft.
Experimental Technology []Subsidence Control ft. ft.
Geothermal(Closed Loop) D Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(ed er,hardness,soil/rock type,grain sire,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed:h///2-'V- We11ID# ft. R. j'
Sa We0 Location: ft. ft. ! .`L j„�� *V E tD
&iP.o 01-1- ft. ft. JUN 2 8 2024
Facility/Owner Name Facility ID#(if applicable)
`:9 / 3 61L-rb5r" CA- ft. ft. Irtn.rx'4+I+C.,i rir:raifts:r,ale
Physical Address,City,and Zip ft ft. acki
/7 21.REMARKS
County Parcel Identification No.(PIN) Tr,V` 4 0 6 t I l< r cP>-- C
r �
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if�well"field,,one latflong is su/ffi icicie�nt)) --�-, r 22.Certification: �^ /�sUbt22keN ` `—D:(.. I/460 3 w [� � /102C(
6.Is(are)the welI(s) rmanent or Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certi0 that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dicti<r E:No with 1 SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well consoactlow 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:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTALI3UMBER of wells constnactwn details. You may also attach additional pages if necessary.
drilled: /�(�/`� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: —` —L�/ (f1-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths jderent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (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: ll 471 (in) 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: 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) / 0 Method of test 24c.For Water Supply&Injection Wells: In addition to sending the form to
I1 f, the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: ►4 4 to 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