GW1--04412_Well Construction - GW1_20240723

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: issm.iiimminir
1..�WJell Contractor Information:
(f; �d. 14.WATER ZONES
l.J FROM TO DESCRIPTION
Well Contractor Name n L q6 ft- AA
ft. f<.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if )
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL/
U ft. 5G ft. 14 in. S'0 PV!
Company Name 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.U1C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft' ft. in.
17.SCREEN
Water Supply Well: PROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgicultural OMunicipal/Public 0 ft• ft. in.
Geothermal(Heating/Cooling Supply) Ddential Water Supply(single) ft. ft. in,
Industrial/Commercial9
Residential Water Supply(shared) 1&GROUT
Irrigation FROM TO MATERIAL ,EMPLACEMENT METHOD} &AMOUNT
Non-Water Supply Well: �� ft' 'ro ft- _f 2L ¢�� �J„'�J�i
Monitoring ecovery ft. ft.
Injection Well:
ft. It.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) °Ttacer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardnea4 soil/rockrya,grain size,etc.)
4.Date Well(s)Completed:rol, 72 3 Well ID# ft' ft
ft. ft. --Sa.Well Location:p��,_ . , • . ► I, %,f y v
Facility/Owner Name / Facility ID#(if applicable) ft' n f� 2024
ICri `hl Q cy51-4 it& ft. ft.
Physical Address,City,and Zip ft ft �j 3r
pc
✓44 1 S Li
I 21.REMARKS �
Cbunty Parcel Identification No.(PIN) - /�'9/ (le I 4Qf ( p
r� ""i
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat//long]is sufficient)� `' i' �/ 22V-).L.-i )6\44.
Certiication: �"�S(A ,,)-6 6 / , I o-N —-7 61.Ob '4)�/ W )r3//O2--(4
6.Is(are)the well(s)�neat or QTemporary Signature of Certified Well Contractor 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: es 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 construction 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 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I LI (B•) 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 1@100) construction to the following:
10.Static water level below top of casing: 19 (ft.) Division of Water Resources,Information Processing Unit,
If wrier level is above casing,use"' 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter Cn "( (in.) 24b.For Iniection 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) /() Method of test ( 24c.For Water Supply&Iniection Wells: In addition to sending the form to
'�� 1 T (( / the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 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