GW1--05011_Well Construction - GW1_20240828

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1. ell Cont or Info mation:
1 l
/0/1 L 1/,el" <L/1 14.WATER ZONES
Well Contractor Name (` FROM TO DESCRIPTION
�79 A 25 zti
fr..
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wells)OR LINER(if ap licable)-""""""��'
Water Wizards Inc FROM ill DIA. ETER THIT7lE,... f T'E �
L/V7// (t. ft.
in. (]/L/CV�jo je�X.I
Company Name 16.INNER CASING OR TUBIN (geothermal closed-loop)
2.Well Construction Permit#: NO TO D ETE:R THl 47 .
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. 101 ft. in'
3.Well Use(check well use): ft / in.
17.SCREEN
Water Su Well:
ppl FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OM pal/Public ft. rt. In.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft.' is
Industrial/Commercial 1DResidential Water Supply(shared) IS.GROUT ,,//
Irrigation PRO I O TE E CEMENT METHOD&ANon-Water Supply Well: ,caG ftG✓ airSM 7'sMonitoringRecovery V R. ft.
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery CISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test D S t o r m w a t e r Drainage ft. ft
Experimental Technology OSubsidence 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 DFSCRIPTION(color,kardaesy soil/rock type Arabs size etc.)
ft. ft.
4.Date Well(s)Completed:7-zQ24 ell ID# ft. R.
a R: /�' "t. ft. AU(, ' ?024
s
ll�L�/%f � }��fl/ Ir.;.:::,....i: . "'- .-,o-, r
Facility/Owner Name^ / / Facility D#(if applicable) ft ft D i; 3
I
Physical Address,City,and Zip ft R.
21. / /d�
County �/ Parcel Identification No.(PIN) S // fe,(�r a r TT- i5b.Latitude and lon itude in de rees/minutes/seconds or decimal degrees: oSep /rk" 'e. 1//w/
n 5' /rel c•
degrees/minutes/seconds
well field,one tat/long is sufficient) 22. e atjp,
N W/ Ir 44/2
7.2442y
6.Is(are)the well(s) Permanent or DTe rary Signature of emfled Date
By signing this form,I hereby cert that the well(s)was(were)constructed in accordance
7.la this a repair to an existing well: Yes or �No with ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out kno,ssr NV/Icons/ruction 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 OW-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: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@l00) construction to the following:
10.Static water level below top of casing: (ft-) Division of Water Resources,Information Processing Unit,
If*vier level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: fin.) 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: 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: 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: 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