GW1--05657_Well Construction - GW1_20240920

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I
1. ell Contractor Information:
leI
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44:WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
NC Well Contractor Certification Number ��J �
15.OUTER CASING NG(for multi-cased wells)OR LINER(if ap hcable)
Water Wizards Inc FROM TO DIAMETER THICKNESS M TERIAL
Company Name 0 ft. 15.-0 rt. Liin. Co i �v/0
�f 16.INNER.CASING OR TUBING(gebthermal closed-loop) ( .
2.Well Construction Permit#: GIN-i II3 a Ills- Zo 2-f FROM TO DIAMETER, THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft ft 1 in.
ft3.Well Use(check well use): R in.
Water Supply Well: 17.SCREEN'
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agricultural DMMunicipal/Public ft. ft. in.!
Geothermal(Heating/Cooling Supply) OReyential Water Supply(single) ft it. in.
Industrial/Commercial esrdential Water Supply(shared) 1S.GROUT -
Irrigation FROM ' TO ' MATERIAL -EMPLACE OD&AMPUNT
Non-Water Supply Well: 0 ft 60 ft Ve.Owe Pdoi C lb if
Monitoring , covery ft. ft.
Injection Welt:
ft. ft
, Aquifer Recharge QI Groundwater Remediation 19.SAND/GRAVEL!PACK(if applicable)
Aquifer Storage and Recovery )Salinity Barrier . FROM TO MATERIAL . EMPLACEMENT METHOD
Aquifer Test (nStormwater Drainage ft. ft
Experimental Technology ©Subsidence Control ft. ft. 1
Geothermal(Closed Loop) °Tracer '20.DRILLING LOG(attach additional sheets if necessary) r- " -
Geothermal(Heating/Cooling Return) fi Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size etc.)
�] ft. ft
4.Date Well(s)Completed:4//I lr,la`7jj Well ME ft' ft. �. F 1 ;- `
5a.Well Location: ft ft "`', e•-.: ` $�L.)
ra I,iN(r -L kr SySlovS ft ft. SEP 2 4 ?021
Facili /Owner Name Facility ID#(if applicable) ft. ft.
ft ft ,v: ,sir-.r,�,t-vS., t
7 " I U P��fry (�1 d1 l�1 p114 .�c�ra�P a+etc,
Physical Address,City,and Zip ft' ft
Q _ / 4- 21.REMARKS ,1
W fl(]�(,(�County Parcel Identification No.(PIN) 211.31-0'I t'L S 1 1 reel 4il' f�o-4 Cv
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: tom' t
(if well field,one lat/long is sufficient) / 22.Certification:
.5' s•k\sitpil ciitg-/aci
�, Signature of Certified
Well Contractor Date
6.Is(are)the wells)i ,ermanent or OTemporary
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing walk J es or jNo with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill outhnonn.merit earstractisr:.t,,,,,,,:....am,erisk'sr the aware of the copy of this record has been provided to the well owner.
repair under#21 remark section or on the back of thisform.
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 pageito+provide additional well site details or well
construction,only 1 GW-1 is needed.Indicate TOTALNUMBER of wells ' construction details.Yon may also attarch additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS ;
9.Total well depth below land surface: 1 _ (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 00'aand 2Q ') construction to the following: '
ed
10.Static water level below top of casing: Qom'h (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,usef+".�/ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: V -/ (in) 24b.For hrjeetierr Wells: In addi to sag the fort to the address in 24a
9 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: r( construction to the following:
(Le.auger,rotary,cable,direct push,etc.) JJ
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSf ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 V
13a.Yield(gpm) i 6 Method of test: p 24c.For Water Supply&Iniection Wells: In addition to sending the form to
,�/y the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 4'l J (
f Amount: `''l tJ completion of well construction tri 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