GW1--04418_Well Construction - GW1_20240723

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
f.L rear1L. 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
1`"77�� A lErg re. I°ID ft. 3 &Pei
-7-7 NC W Contractor Certification Number d ft. .3 n '1 / P Ni IS.OUTER CASING(for multi-eased wells)OR LINER(If a &able)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. l0 3 n b'yt st i PvC
16.INNER CASING OR TUBING(geothermal closed-loop i re r
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS,S,� MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) a 'T0 ft• •7 S ft• y tn' Sd- P VC-
3.
Well Use(check well use): LJ ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public rt.
ft. In.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft.
Industrial/Commercial Residential Water Supply(shared) I&GROUT
Irrigation FROM TO t MATIE/RL/L r EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft' (0 3 ft' YccUin 4C(q Poured t J N p -
EiMonitoring Recovery n n -J fn n1 _ _ _ /ie„x I bS
Injection Well: / `"(1)/1�L.� (�i�
Aquifer Recharge QGroundwater Remediation n 3 n N&L4 1��r� �� I
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 D. n
0
Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional steers If necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiVrock type,grain size,etc.)
4.Date Well(s)Completed:t� -� Well ID#I3,- L[S 16 n aQ n 6-(mac/ C
n n
5a.Well Location:`
Cl S PLei?S n n /::
Facility/Owner Name Facility ID#(if applicable) ft. ft , k
L1'7 1'1 . (,1,ee_ Mal Rd QoIboro o7X"7'1 n ft. - JUL 'L 2024
Physical Address,City,and Zip
21.REMARKS
e('�O I'1 117n:7.-4A:us: .7..se,4:-,0
County Parcel Identification No.(PIN) D'f.Lr Lv
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3i:7-4c7(19/ N -79.00S7'1e W Iger;fr... .ft...._
4-1 77 (4 -AD-aif
6.Is(are)the well(s) ermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or @Kr with ISA NCAC 02C.0100 or/SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known Nell eowstniaron 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 nee•.esary.
drilled: ^/ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 060 (k) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if d erent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: t'Od2 (ff-) 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: (Q l" (in.) 24b.For Weeders 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: A:r 12,Q'I7'dr y 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) "6 Method of teat: bi,Jnc2i min t 24c.For Water SuDn1v&Injection Wells: In addition to sending the form to
``'' II II the address(es) above, also submit one copy of this form within 30 days of
CI'13b.Disinfection type: 1DI Amount: i a C)7 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