GW1--04984_Well Construction - GW1_20240828

Print Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1. ell Contrac r Information:
g/ 1/af1t4h 4' ///CAm{C() 14.WATERZONES
tFROM' TO DESCRIPTION
Well Contractor Name
27 q6 41 ft.ft. ft. Pig,•) IvG -/ u'P
n
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable) /I
Water Wizards Inc FROM TO D1A. TER THt NESS MATERIAF
1 2 C' in. 55- (Gi i.
Company Name �Gj 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: W L1'0i1O"1 FROM TO DIAMETER TH C NETS rye.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) C' ft. N 2 ft• y in Y� r/l C
3.Well Use(check well use): ft. 1ft. to ���G///��/ VV
Water Supply Well: 17.SCREEN
�jOM DI R SLOT SIZE THICKNESS M} RIA
Agricultural DMunicipal/Public (/.'Zft �u�it in /' /�
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) T ft. ILL [ ft. is I
In . I/Commercial DResidential Water Supply(shared)
1&GROUT
rrigation FROM PTO TE LACEMENT ME o00D/& U T
Non-Water Supply Well: ft /2 ft G;f,J P / _ �(l 7 T
Monitoring ORecovery ft.
Injection Well:
ft. ft.
Aquifer Recharge QGroundwater Remediation
—
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additloaal sheets if necessary)
Geothermal(Heating/Cooling Return) QOther(explain under#21 Remarks) FROM TO DEscwP r1oN(ceYr,tuudaer soiuroel type,grain size,etc.)
ft. ft.
r
4.Date Wel(s)Completed° (/Q 21/ Well ID# , ft' i ft ( , ;
5 e0 Loc 'on: ft. ft �- ...
lA d `//1- ft ft AUG ? S 207�
Facility/Owner/ e / Facility ID#(if applicable) ft' ft.
>V Na�/ �S�p 3 �j N R If.i:.,:E..e, r t,!{� t
Phys l Address,City,and Zip ft. ft
ARKS/
CAu49,e u[A, aria/
;i p/ c/e,,
l /2"
County Parcel Identification No.(PIN) /
ilk
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 3' eo P i , , cri e-/7
(if well field,one lat/long is sufficient) 204"/, ,r� ,, e!f
N W / —! '-ZV
6.Is(are)the well(s) Permanent or Temporary
Signature of Certified Well on.. tor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or ONo with I5A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known NrdI eonstrmrtrow iwfon taboo and explain the where 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: / c (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@20 ndd 2@100') construction to the following:
10.Static water level below top of casing: v (ft-) Division of Water Resources,Information Processing Unit,
if water level is above casing,use C, 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 7 t (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: W
� 7 r-// 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 WELLSONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 L` Method of test: f /Tt' 24c.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:C�J!(,'1./)p Amount: eel) 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