GW1--05680_Well Construction - GW1_20240920

Print Form .,1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
.
1.Well Contractor Information:
6..Ci k14.WATERZONES - • 1; $'
Well Contractor Name VROM TO I DESCRIPTION
ft-
NC Well Contractor Certification Number ��f L' •�� "- �
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Wizards.Inc FROM TO- DIAMETER . ETHICKNESS MA
Company Name 0 ft. 3 fL ( Y ,° in- $*Q Pv C
16.INNER_CASINGOR TUBING(geothermal closed-loop)L Ty1...�-
2.Well Construction Permit#: • FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 6 K- fly t}. L ' 1n. Sti,g© P u c
3.Well Use(check well use): ft ft i°'
Water Supply Well: 17.SCREEN
FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
®Agricultural CjMunicipaUPublic ft. ft. In:
I®Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in:
E,Industrial/Commercial DI Residential.Water Supply(shared) 18.:GROUT
I Irrigation - FROM TO MATERIAL 'EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0
ft. R *lief #
®;Monitoring [jRecovery_ ft. ft. SS'-30 16 s
Injection Well:
*Aquifer Recharge 0GroundwaterRemediation 0 f n " ZT 36 11s
•r 19.SAND/GRAVEL PACK(if applicable)
21'Aquifer Storage and Recovery 0 Salinity Barrier FROM TO. MATERIAL EMPLACEMENT METHOD
( Aquifer Test IDStormwater Drainage
®Experimental Technology IDSubsidence Control ft. ft.
Ili Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM _ TO _DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks) - ft ft. Lie r
derl
4.Date Well(s)Completed: 1- q' Well ID#V�1(b d r9 rat 1, la ff. 10 ft. Pn ec (e
5a.Well Location: • I 0 ft, -3 ft- 1�.' Y O
•
i'tc-kr4 Pro 4-or 36' ) so 61-zxy cork__ _ ,y__. .
Facility/Owner Name Facility ID#(if applicable) ft. ft. f -• , a .j
' 1�s�1 Allen Creed R �4- ft. ft. S E P �24
Physical Address,City,and Zip ft. ft-
21.REMARKS
��G1 Sot\ IftiG'.-:iri•.-v:t F ,-I'.- •.-ii,'r" .JS::+
i County Parcel ldentificationNo.(PIN) (� f i.'124-V3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 1 i i 22.Certification:
sufficient)N ? �9 LI6u195r W _ 46.7 7 i- -e241
6.Is(are)the well(s) Permanent or jTemporary Signature of Certi ed well Contractor Date
By signing this form,1 hereby cert(5.,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ''o with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known null cows/met/ay isfolmratian 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 GIN-1 is needed-Indicate TOTAL13L)MBER of wells eonstwr-tion details.You.may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Ki"C) (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: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
W11.Borehole diameter: & (in.) 24b,For Injection Wells: Its addition to sending the form to the address in 24a
/1p� /11�t _` above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: a 6` '7Cl 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:e)1C(.) ) 2` /1rjy 24c.For Water Supply&Iniection'Wells: In addition to sending the form to
(41.14 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: I)• oZ 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