GW1--04415_Well Construction - GW1_20240723

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well ContractorInformation: '
/`` C V`.• W Q1 v 14.WATER ZONES
Well Contractor Name PROM TO DESCRIPTION
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 3 O rL LI in' SCw NV 1 VC
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: PROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft• ft. is
3.Well Use(check well use): ft' ft in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public ft. ft. la.
Geothermal(Heating/Cooling Supply) gresidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO t MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 00 ft. N�f1/ f tor,*_ AO 1 b$
Monitoring DReeovery ft. ft.
Injection Well: ,
Aquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStorwater Drainage ft• ft
-
m
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 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 sae se.)
/- �j ft. ft.
4.Date Well(s)Completed: & (0'2 4 Well ID# /4 61 l 3 0 ft. ft• •4 i
ft. ft. .%4.. � �fy..
5a.Well Location: l l+L./
2Sck Li t")pR.p ft. ft. FrAJUL 2 2024
ft. ft.
Facility/Owner Na a Facility IDS(if applicable)
7 OS Q E`T'it ft. - L.L S(*COL- jZ0 ft. ft. [Rt ti.a' t,
Co-
PhysicalAdddress,City,and Zip ft. ft
Pt5ASeN 21.REMARKS ���
County Parcel Identification No.(PIN) C"4 OFF Cr p 5744( pNe To
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Lt1A)(X)J L1 1%)14 is N T 1' R 14Tn15
(if well field,one lat/long is sufficient) 22.Certification:
3(2 $O733644 N - 7Y. gkS 603t'(t► W NTGk,_ ow••►Scs .1 0 - 10 -Aq
6.Is(are)the well(s) ermanent or )Temporary Signature of Certified W 1 Contractor Date
By signing this form,I hereby certifr that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: gfes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known sell earstrarlron infrnmatinr and explain the nature of the copy of this record has been provided to the well owner.
repair under#2I 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You.may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: i a' (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@t200'and 2@t100') construction to the following:
10.Static water level below top of casing: A.S. (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: 5 7'1, (in.) 24b.For Iniectioe Welly In addition to sending the form to the address in 24a
12.Well construction method: R oTR)\Li above,also submit one copy of this form within 30 days of completion of well
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
1
13a.Yield(gpm) w+ Method of test: P�N 24c.For Water Supply&Injection Wells: In addition to sending the form to
Q the address(es) above, also submit one copy of this form within 30 days of
t
13b.Disinfection type: NT H Amount: I 6Z. 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