GW1--05670_Well Construction - GW1_20240920

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
h ()PIP', ' 14.WATER ZONES 1
Well Contractor Name y FROM TO DESCRIPTION
3 02."1 Z 70 ft. 27 y ft. / ! /
NC Well Contractor Certification Number f 70 0.
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Wizards Inc FROM TO DIAMETER THICKNESS pfI MATERIAL
Company Name 0 fL //J O fL (-I In. L. NO I
16.INNER CASING OR TUBING(geothermal)closed-loop)Wi l
2.Well Construction Permit#: FROM ' TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i e.UIC,County,State,Variance,etc.) ft. ft. i in.
Well Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN „
� FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
N l'_:I Agricultural unicipal/Publie ft. ft. in.
ill Geothermal(Heating/Cooling Supply) g Residential Water Supply(single) ft. ft. in.
111 Industrial/Commercial DIResidential Water Supply(shared) IS.GROUT '' •
I ,Irrigation FROM ' TO p, ft. .. T�' MATERIAL ' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 3_/ iI Wol c pi/p -
`Po.4 .I/Gras
A Monitoring 9Recovery 0 ft ,�^^11 ft /
Injection Well: I yV ��e / Osft. ft. (((
®Aquifer Recharge Qi Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
IIIi Aquifer Storage and Recovery DiSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
III Aquifer Test 0 Stormwater Drainage ft' ft'
Mil Experimental Technology IOSubsidence Control ft. ft.
a Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,r,hardness,soli/rock type,grain size,eta)
Geothermal(Heating/CoolinggRetu [irn) Other(explainunder#21 Remarks) ft 7 ft. 191/ � �/[i'1 r
j
4.Date Well(s)Completed: 1"->ur-2f Well ID# 7 f' 31 ft st. t,c-1t nn(f c.
Sa.W Il Location• 31 ft, 11 ft.
/J► /g GN i'" ,�_. ,3_ ;
O�; LC ./ rvai ft. (�tJ ft.
a•t •2,.� . -�7..,c✓
Facility/Owner Name D Facility ID#(if applicable) ft. ft. S E r 2 0 t4
1-090CCFces )/r//short tiYLG ft. ft. ;
_ J Ir.•-c- :^--s,r--. ?.r r af:,., -rt 1-
Physnical Address,City,and Zip �•f/• . �i7's ft. ft IY ia� !G a ~
Qurtic." 1 g g373 21-&MARKS L
County Parcel Identification No.(PIN) TplC.7Nr, vT lid )1 A` t/km;,- `
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: / 1 LA rri"3 bf-l../ J t.\ !SS c.vt S
(if well field,one lat./long is sufficient) 22.Certification:
36•/2S10(t)0 N -7A•91-99669 W
6.Is(are)the well(s) ( Permanent or Temporary Sigma of Certified well Co ror Date
By signing this form,1 hereby certiry that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or DI< with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known uul/conrtruetion 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 fonn.
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 Tt7TAL13UMBER of wells constxuctton details.Yea may also attach additional pages if necessary.
drilled: f SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: , 100 O 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@I00') construction to the following: ,
10.Static water level below top of casing: 25- (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+/+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: Y/1.3 (in) 24b.For Injection Wells: In addition to sending the form to the address in 24a
/� --LL above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: K.0 T 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
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13a.Yield(gpm) 3 Method of test: iC//*a it 24c.For Water Supply&IniecBon'Wells: In addition to sending the form to
� / the address(es) above, also submit one copy of this form within 30 days of
/
/ i 13b.Disinfection type: 1.F' Amount: ! O 4ss.t 5 completion of well construction to the county health department of the county
where constructed.. I
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016