GW1--03884_Well Construction - GW1_20240628

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
15 4_, 14.WATER ZONES ,,/],�
PTION
Well Contractor Name 'FROM TO n%�CJe
L --G )ft.
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING(for multi eased wells)OR LINER(if ap livable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name f/ ft. CI b ft. £4 in. Gfla _P/ �1 iT
16.INNER CASING OR TUBING(geothermal closed-loop) V
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pernriu(i.e.UIG County,State,Variance,etc.) R. ft. in.
3.Well Use(check well use): ft" rt. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER , SLOT SIZE THICKNESS MATERIAL
Agriculture[ OMunipal/Publie ft. ft. In.
Geothermal(Heating/Cooling Supply) idential Water Supply(single) rt. ft. in.
Industrial/Commercial OResidential Water Supply(shared) 1S.GROUT
Irrigation FROM TO TO ' MATERIAL r EMPLACEMENT ME OD&AMOUNT
l)
Non-Water Supply Well: ft. Ci i . t. fr - Q(zQ,i 7 3 6U/45--
Monitoring ORecovery
Injection Well: ft R.
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 ElSubsidence Control ft. ft
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sire,etc.)
Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
4.Date Wells)Completed: 41/ki/je Well ID# \06\ C\ ft. ft. ' `` \.•L_' jt Li
ft. ft. p 1
5a.1 Well Location: ft. fL JUN O 2024
'4/{/Y' J�'1e.wd i( 6t ft. ft r
Facility/Owner Name Facility tD#(if applicable) . lr.f :.,&.i tj i.♦ ,i.r�yam,` Litt
2
JQ ( f reel 114D44't 124
ft. rt. Mr(„1,SCA;
Phys' I Address,City,and Zip ft' ft.
2L REMARKS ,y� /)
County
O N Parcel Identification No.(PIN) ";fRE i5Y 27r`/'�Z 1 i` - 1( Q.A.AC'sr/
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Cis
(if well field,one ttatt/llonng is
sufficient)
/ p� y;�1 / d 22.Cerrtificcatio�n: /� /
SG .-G`�1-I 1/0 N ?_I.0 3Vl)!(a'/ W 1l/' - - /'2) /Q2i(
6.1s(are)the well(s)1erinanent or Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Q ies 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 co/tans-Alan 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 OW-1 is needed. Indicate TOTALNUIsIBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below laud surface: (3t-./LJ (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: r-9. (ft-) Division of Water Resources,Information Processing Unit,
If water level is above casing, '*' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: Le et-t' (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(pm) 3 Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
I , 'jj the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: f'TI P Amount: Qu-s,./ completion of well construction to the county health department of the county
where constructed.
Form t)W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016