GW1--05679_Well Construction - GW1_20240920

I Print Form I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1. ell Contr tor Information: • I
I I
,�Lt-/1 oil '[/1/ j 1//(Jy,4f) 114.WATER ZONES P !
dlWell Contractor Name 1 rpi. T i?has
A 2 7 q6 A 1q jft. /_ f,/)� 'I,,t (' Rif)-e
NC Well Contractor Certification Number • 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Wizards Inc FR /OM T D TER THIC S MA
ft ft.
Company Name "' �
(Yet i
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO D TER TmC ESS TE
pLe
List all applicable well construction permits(i.e.Ult,Counry,State,Variance,etc.) o ft. ft. in• 5'c 1-(0
3.Well Use(check well use): ft ft In, (V
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
®Agricultural Fipieial/Public ft. , ft. la.I
III Geothermal(Heating/Cooling Supply) dential Water Supply(single) ft ft M.
)I Industrial/Commercial DResidential Water Supply(shared) 18.GROUT .
I 'Irri•ation PROF T w D L E,J LACEMENTMETHOOD gI1NT
Non-Water Supply Well: 0 ft 5-ft 0. I�,�7I©r, ' 3 tI
•Monitoriing Recovery V ft ft. f/�
Injection Well: I ft. ft
I Aquifer Recharge DGroundwater Remediation '
19.SAND/GRAVEL PACK(if applicable)
11;Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
If Aquifer Test IDStormwater Drainage ft. ft.
a Experimental Technology El Subsidence Control ft. ft.
all a Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary) •
FROM ' TO DESCRIPTION(color,hardness,sett/reek type,grain size,etc.)
IN Geothermal(Heating/Cooling
Return) Other(explain
�junder
p#21 Remarks)/_ ft. ft.
4.Date Well(s)Completed: / 12 r 2We11ID1i: t-f 5D- I tog ft. ,`+ i
Sa WellL ratio ft ft. " ► • +i 1� I
/l `.L
ilei%/ht P/�� �QYI�'jf ft ft • S P 2 O rfl2a
Facility/Ow erNa Facility #(if applicable)
R. ft. ir�y
7 �'l /t / !') �GA/J(/!U ft. ft. ' (.t DIM',
, .-.., : lire
pcai Address,City,and Zip I ft. ftc 2 MRKS, f, g ty (PIN) j /4 ci °o'/tC / 11/),D f c /:.
Coup ParcelldentificationNo. /' /•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: / /0'7 1,n
(if well field,one tat/long is sufficient) 22, atio.
N W �/ 22C/ .
6.Is(are)the well(s) Permanent or DTe u porary j signature of Certified a Con Date
By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: (41 Yes or [jNo with 15A NCAC 02C.0100 or 15A NCAC;02C.0200 Well Construction Standards and that a
I
If this is a repair,fill out known wileonstnettav infmrnation and explain the 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 GW-1 is needed. IndicateTO(TALNUMBER of wells construction.details.Ynu may also attach.additional pages if nerensary.
drilled: SUBMITTAL INSTRUCTIONS ,
9.Total well depth below land surface: i CCO ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdterent(example-3 00'and 2@a 100') construction to the following:
10.Static water level below top of casing: 0 (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: (in) 24b.For Injection Wells: Ia addition to sending the form to the address in 24a
I
/��/ 1 above,also submit one copy of this,form within 30 days of completion of well
12.Well construction method: `Il,t/ y construction to the following: !'
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPL LLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
�1 I
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: C ff•Y!� Amount: 2 ( ,J completion of well construction to thei county health department of the county
where constructed. !
1
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016