GW1--04417_Well Construction - GW1_20240723

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
ts ( 4 J 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
Gl14 fr r_G I b ft god ft 76oci
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(If a le)
Water Wizards inc FROM ' TO DIAMETER THICKNESS
t l��TEE[RRIIAL
Company Name ft. 7 1IL —! try 1V `
16. NER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER_ THICKNESS — MATERIAL
List all applicable well construction permits(i.e.UDC,County,State,Variance,etc.) ft• ft. in.
3.Well Use(check well use): ft ft in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ❑Municipal/Public it, ft. IL
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) rt. ft. Ia
Industrial/Commercial Residential Water Supply(shared) IS.GROUT
IrrigationFROM t TO ' MAATERI�AL t EMPLACEMENT ME D&AMOUNT
Non-Water Supply Well: 6 ft- 2 ft- �4 4 pole 7 es- 6V.)-
Monitoring Recovery ft. It Cd4��''
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19,SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Ba[tier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. It
Experimental Technology El SubsidenceControl ft ft
Geothermal(Closed Loop) QTtacee 20.DRILLING LOG(attach additional sheets If necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM fL TO DESCRIPTION(color,hardness,toil/rock type,grain size,etc.)
n IL
4.Date Well(s)Completed: �lpL-/ Well ID# 1 ft. ft.
5a.Well Location: ft
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Facility/Owner Name Facility ID#(if applicable) ft. ft. i J L 2 _ 1024
3 o �I/��, ft. IL
ram,;; s UrI:
Physi I Address,City,and Zip ft ft If.ti.: A• "
�Qf 5 ^ ��u' a 21.REM_ARKKSS / /_ '` ( DV.C.e�Lv
Cotlhty , ` Parcel Identification No.(PIN) r" �l` I '>YJ 1
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
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(if well field,one fat/long is suffiient)) 22.Certificado �/
30r a ICI ` 16 SiJ !N' 41 T(I 13 W VA i ?Nt Iu --)%GWt?""r
6.Is(are)the well(s) anent or Temporary Signature of Certified Well contractor Date
�,// By signing this form.I hereby certty that the well(s)was(were)constructed in accordance
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7.Is this a repair to an existing well: ls 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 Hell consttartr'aw information and explain the nature of the cop. 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: SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: o (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: G 14J (in.) 24b.For Iaiecttoe 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&Injection Wells: In addition to sending the form to
L _ /( the address(es) above, also submit one copy of this form within 30 days of
1
13b.Disinfection type: 'J 4' (i 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