GW1--04411_Well Construction - GW1_20240723

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information::
:C IM , I 14.WATER ZONES
Well Contractor Name Q FROM t TO DF.SCRIPT10N
3oVi ••A 415-ft. '�d ft. y corn
NC Well Contractor Certification Number 2rs 15.OUTER CAST 2P. ft. Li4'r1
(for multi-cased wells)OR LINER Of ap licable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
CompanyName 0 n Io �- q in- y P�
16.INNER C 1NG OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO s DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. 1n.
3.Well Use(check well use): ft ft in. .
17. N
Water Supply Well: FROM TO
TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OM cipal/Public ft, ft Ia.
Geothermal(Heating/Cooling Supply) Deesidential Water Supply(single) ft. ft, In.
Industrial/Commercial DResidential Water Supply(shared) I&GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 10 f (03 6'fi / "Ay',oil.-,f V 0/ AS
JMonitoring Recovery it ft.
Injection Well: i Oa CasiotraiLeo// if d Dfbs
ft. ft.
Aquifer Recharge QGroundwater Remediation -
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach addltioul sheets if necessary)
Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,wiUroel type,grain eizq ate.)
4.Date Well(s)Completed: 7_i-.24/ Well ID# O jg L/4
Sa.Well Location: 38 fL Zito' C^C ui te94./41 i J(s 6,.;
ft. ft.
(eil Ctiv6r" ,) r+��
Facility/Owner Name Facility ID#(if applicable) ft. ft `.j�_ `' "`
D /.r�. ft ft.
� -
- T. ye....;, tiT7
Physical Address,City,and Zip �- ft ft 1i Oq,..r'.5-A-3
Prise" 21.REMARKS 1-
County Parcel Identification No.(PIN) C/Q`(R l (/`/I,1.ir'® b 1 FT
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: /n '4J/4 ' gdf!A 1;M t/
(if welt field,one Iatilong is sufficient) 22.Cn:
36,g27Y3‹ N - 74.51o5ss W Certificati
30 Z2/ 4 7-5-exr
S�fCertified Contractor Date
6.Is(are)the wells) ermanent or Temporary t�
��,t� By signing this form,1 hereby cert that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or AO"" with I SA 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ZDQ 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@t200'and 2@ 100') construction to the following:
10.Static water level below top of casing: ? (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: (0 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
n �� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: o?�r 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) g Method of test: Pip 441 lsh124c.For Water Supply&Iniection 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: fr/71-1 Amount: /4t„,,,,43 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