GW1--04414_Well Construction - GW1_20240723

IPrint Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Err L COOL 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
1-IS-1-) tax ft. 13o R 1 (7-Pr-1ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a ble)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name0 ft. 63 ft. 41 Yy in' LI PVC
U.INNER CASING OR TUBING(geothermal closed-loop) nee
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft.
VO ft- LI ia. !'/'1 1 C./ P v^
-1/0
3.Well Use(check well use): ft ft. 1 in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
()Agricultural ()Municipal/Public ft. ft. la-
Geothermal(Heating/Cooling Supply) ()Residential Water Supply(single) tL ft ia,
()IndustriaUCommercial ()Residential Water Supply(shared) is.GROUT
"Irrigation FROM ' TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 473 ft- '16401,4ILt q fixrEci cl-- HyrIt,
°Monitoring ()Recovery ft R. „J (�la.�j (� b
injection Well: dirt ,�,,�,j (� r +�, $
()Aquifer Recharge ()Groundwater Remediation 0 B D� Nett+ CE t3 n Pc a I W
19.SAND/GRAVEL PACK(if applicable)
()Aquifer Storage and Recovery ()Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
()Aquifer Test 0Stormwater Drainage ft' ft'
()Experimental Technology ()Subsidence Control ft. ft-
()Geothermal(Closed Loop) ()Tracer 2A.DRILLING LOG(attach additional sheets if Necessary)
()Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(cater,aardaew sdl/reck type,grain oar ear)
r� /� /� 6 ' a R 0✓e.4-1 _
4.Date Well(s)Completed:6-ral S- y Well ID#A 3s-Lit°it cR ft- la ft- Q ., 1
5a.Well Location: I a ft. Syv ft. /74--eG �X ,.. ,- . t
.. ft. v. Y ((«)QQ y . ..e... ill._ ..)
T`"Y'"'' ik-fc Dr,nulct ft. ft. JUL 2 202�
Facility/Owner ante Facility iD#(if applicable)
qcs t 1c( €es n4:I1 im kcvio a7siii ft. ft.
Physical Address,City,and Zip ft. ft. IrtIt-g i,.4rtC,: 'E'r.7„,ri:-� pl.
PerS0 f 21.REMARKS DAL.
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.Certification:
3(v.4iS'S"33lo N --71 e OC O`d3S w L{S? -,A�'-�
6.Is(are)the well(s) rmanent or ()Temporary rgmhrre, ern ell Contractor DateZi4 to
By signing this form,i hereby certify that the well(s)wets(were)constructed in accordance
7.Is this a repair to an existing well: DYes or with 15A NCAC 02C.0100 or 154 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: l SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: s�Iv (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 22-@ 100') construction to the following:
10.Static water level below top of casing: c9 (fL) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1,// 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: /0 I/ (in.) 24b.For IRiection Wells: in addition to sending the form to the address in 24a
A.. � � above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: ,f 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(gpnt) I Method of test:Mi, 1 11y r-CS n 24e-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: t+7l7a Amount: V 6)Z. 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