GW1--05005_Well Construction - GW1_20240828

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Lc' C e_co I 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
1tS 5C) " y l&P�t
yS7`7
NC Well Contractor Certification Number 9 v
15.OUTER CASING(for multi-cased welt)OR LINER(if applicable)
Water Wizards inc FROM TO DIAMETER THICKNESS lI•
M RIAL
Name0ft. ,9 CI R. �, Sl) a I tic
Company16.INNER CASING OR'TUBING(geothermal closed-loop) 1
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): Ot ft. is
17 SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
BAgricultural QMunicipal/Public ft. it. la.
Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft ft in.
QIndustrial/Commercial DResidential Water Supply(shared) IS.GROUT
f Irrigation ) FROM 1 TO MATERIAL-7-1 EMPLACEMENTMETTHOD&AMOUNT
Non-Water Supply Well: 6 ft it /13 t lepi j 1 Dr�CI°_ *Cork
Monitoring DRecovery ft ft. Irl ek '7�Ce lbS
Injection Well:
ft. ft.
BAquifer Recharge 0 Groundwater Remediation IF.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test QStormwater Drainage ft. ft.
Experimental Technology QSubsidence Control ft. ft.
!Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if Necessary)
Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hard•ese saVroek type grain sire etc.)
o ft. a ft. o Ofu-bf,rds`r1
4.Date Well(s)Completed:'1-1,21.214 DO p? ft
Well I . IT ft' /
Sa.Well Location: 1 5 ft
03 ft 5a- d
'L-4e S l_lo rs-,eS a3 ft. 300 ' G-rai koLA_ x i
Facility/Owner Name Facility 1D#(if applicable) ft ft.
1633c CZLa;I 614 Pd, fc.A1-1-sarsm1 C2?S o?1 f. ft. AUG 2 S 21324
Physical Address,City,and Zip ft ft
�r���lM 21.REMARKS iG:;:%".:...:-1 , % ::fir,: 2 :...l
DAD..,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36.I%763a2 N -71r• 10'11 ,9 W y577 A 7-la-.24
6.Is(are)the wells) 'ermanent or QTemporary Signature of Certified Well Contractor 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 Yo with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fell out known well cotxrtmetiaw infreweatiotrand explain eke nature ofthe 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 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if tu+rnecary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 300 (ft-) 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: aan (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: eg IA( (in.) 24b.For lniectioe Wells: In addition to sending the form to the address in 24a
11 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: A;r- 20"F Q 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) L3 Method of test:Q 10(,yt cs2Jfsi1t 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: N1-M Amount: I LI O Z 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