GW1--03891_Well Construction - GW1_20240628

Print Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
✓�J ^
�N� Vj /,/�' 14.WATER ZONES
Well Contractor Name FROM TO t nE6CRtPSIO41
3021/-4 .:' ft. .3� ft. 3 �IPi7
ft ft.
NC Well Contractor Certification Number • 15.OUTER CASING(for multi-cased wells)OR LINER(if ap ' le)
Water Wizards Inc FROM TO DIAMETER THICKN S MATERI
Company Name U f. bi ft & . 2/ 6AL
-
lb.INNER CAST C OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO 1 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. 1O
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural rcipal/Public ft, ft. I..
Geothermal(Heating/Cooling Supply) 0 esidential Water Supply(single) ft. ft. la.
Industrial/Commercial DResidential Water Supply(shared)
I&GROUT
Irrigation FROM TO '7(g/'MATERIAL enMPLACEMENT MC.,AMOUNT
Non-Water Supply Well: 0 ft.
/„`� ft' i/8Zt/7oiL �r-w�'�///our C�-ram/
Monitoring Recovery ft V// :
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test fStormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) �J DOther(explain under Remarks) most TO DESCRIPTION(color,hardness,soiVrock type Brain siu etc.)
4.Date Wells)Completed: `/ Well ID# A(-/ / /3g 0
' OvC�/c�n
'7 iL Ill —
Sa Well Location: /t. ft. c� ft. �c, .'G�mil' ,``_ i i
ft ,� 'l �..'; �t 1.
LyrIe> kf_�,
Facility/Owner Name Facility Mit(if applicable) ft ft.
JLiA. 9+ 8 2024
f �o n ft ft ft...,„...„.,...., _
> ` Lf y�C1s�'rot ft. R an... Sy .
Physical Address,City,and Zip Z7�7�/ DI.— 3
PC fr,fC? 21.REMARKS
County � Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one lat/long is sufficient) 22.Ce lea• n:
36 cf_67& N -78,9'R1g7 w g2 — s-N-2r/
6.Is(are)the well(s) ermanent or OTemporary Si re of Certified Well C ctor Date
�--�� By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or Dr with 15A NCAC 02C.0100 or 114 NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well conrtrurtlon information and explain Ike 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 rietaits,. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 4—/O6 (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@200'and 2@100') construction to the following:
10.Static water level below top of casing: 2-/ (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: ea 4 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
/J 1 Df- above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: (K1 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: ,,nn'' 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test:' //)/./ i 7�i'H i,-, 24c.For Water Supply&Injection Wells: In addition to sending the form to
/ y � the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: r/ // Amount: I t�Q ear)(L, 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