GW1--04397_Well Construction - GW1_20240723

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
t_c-'.L (ix>k 14.WATER ZONES
Well Contractor Name ' FROM TO DESCRIPTION
ys7.7 a is ft- ft 6-Pell
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap likable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name D ft- 100
ft / in In. spZ I P VC.
iu 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit ft: q. 3 1 l 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): ft. ft 1°
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft, ft. in.
Geothermal(Heating/Cooling Supply) E esidential Water Supply(single) ft, ft. in.
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
Irrigation FROM , TO i MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft- (U U ftPot r- l kJ ;n
Monitoring Recovery I ft. ft. / � kpj7O�I (LInjection Weil: ft_ ' ft. ' I It�t � j I�j V
Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft- ft.
Experimental Technology DSubsidence Control ft ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color hardness soil/rock type grain size,ere)
0 ft- a It t, bwtr
4.Date Well(s)Completed:6:-I¶-e ? 1 Well ID# c9 ft ,514 a ,J C
5a.Well Location: J-I ft. f iro' 6-rel L ,.k
Rid Der• �t,r,eS ft. ft. _ .-- ; f -
Facility/Owner Name Facility IDS(if applicable) ft. ft. �...�. a.. Iif ,
6s Qt..r- .►sc T Dr- I-eilcr5or �7S37 ft ft JUL 2 ,; 2024
Physical Address,City,a Zip
21.REMARKS ifri3:::�6.%:,i ;'-r"3tsa ' 'Jr
v�^C�
County (PIN) �'1l GantS Hydro creitJt d D'/ .. _.��
Parcel Identification No. P[N
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34,305f31A N -746-90ya9, W �(s77 4 �-14s-ay
6.Is(are)the well(s) Permanent or Temporary SigratureofCertified Well ontractor Date
By signing this form,I hereby certt&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or INo with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out knosw Nell cowstra+clorw imfrirmatioa 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 derails. You may also attach additional pages if necessary.
drilled: � SUBMITTAL INSTRUCTIONS
if'
9.Total well depth below land surface: frie) (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd(erent(example-3@200'and
d22@100') construction to the following:
10.Static water level below top of casing: OS-0 (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: (O I/O (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
/I., (�P. above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:air / 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) d Method of test:Q btJr'1 ,rh';n 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:��rT Amount: lb OZ 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