GW1--05010_Well Construction - GW1_20240828

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WELL CONSTRUCTION RECORD(CW-1) For Internal Use Only:
1.Well Coat tor Information:j314 //7) 14 ! 11/4i ` (1 14.WATER ZONES
Well Contractor NameM TO I DRSCRW TION
27y� �J 7fOc: vi :
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wells)OR LINER(if ap •able)
Water Wizards Inc ►�tQM Ty 3 D ETER THtctfNEss nt4TEAL.v.
U rt. (� ft. in. 1J�7 C/prrr'J
Company Name lb.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: CAM J?a DTER relc E�s� mA/E>�
List all applicable well construction permits(Le.U1C,County,State,Variance,etc.) 7 ` (, 1 S J// ((J�l//
3.Well Use(check well use): ft. ff 1O
Water Supply Well: 17'SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OM ipal/Public ft.
ft.
In.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) IS.GROUT
Irrigation FRO TO T ETHOD&AMOUNT
Non-Water Supply Well: V ffl ( p7LJ°Monitoring ['Recovery % y
Injection Weil: ( ft
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(H applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ff' ft.
Experimental Technology Subsidence Control FL ft.
Geothermal(Closed Coop) OTracer 20.DRILLING LOG(attach additieaal sheets i<oseessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type grain size,etc.)
''''n� ft. n
4.Date Well(s)Completed:g�22 20Lywell ID# ft. ff
5 Wel Loatu: n ft ft.
'
t,.. ' ..-.
Pv14' Y,? c76:/ it, ft. AUG 2 6 ZUZ4
Facili /Owner Name Facility #(if applicable fl ft
a2 s//7P1 t,// e) C el , tl/ ft. ft. 11,.,...,...D, :• , ;
P tc/il Adds,City,and Zip ft. ft.
h/ 1
041 21.REMA ` oe, ,7c.,„ .�y
County Parcel Identification No.(PIN) f ��� e� :�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: c�f/r (OK
(if well field,one Ialllong is sufficient) 22.C afio
N W T Z2-2C2
6.Is(are)the well(s) ermanent or DTemporary ignatute of Certified Well Con or Date
By signing this form,i hereby certefy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or ONo with 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well ewnrinietiow 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 cnnstnuhon details. You may also attach additional pages if necessary.
drilled: �j SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: co J (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: c(v (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: s((/� (in.) 24b.For Injection 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: /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) Method of test: U 24e.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: P 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