GW1--05685_Well Construction - GW1_20240920

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Print Form i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1. ell Conti for Infrrmaation: i
F.
17 O/?� l�1O ltf(i`Grrl1 j��l)C /r� .14.WATER ZONES I i
Well Contractor Name OM TO DFSCR N
2� ,� r7o
ft /7/ fft. ftI/
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased'wells)OR LINER(if ap ticable)
Water Wizards Inc FROMl TO 7 DInr,TER THICKNESS MATTF,RIAL/�
V ft. ft (p i, in. 77 6
Company Name
16.11.714ER CASING OR TUBING(geothermal doSed-loop)
2.Well Construction Permit#: W a Can g, FROM TO DMIETER THIC A ERIAL?
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) a ft. 0 ft. in. /f� 7t V /
3.Well Use(check well use): ft ft. in. �f // V
Water Supply Well: :37.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
®Agricultural cipaLPublic tt fr la
III Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft in.
®Industrial/Commercial DResidential Water Supply(shared) IS.GROUT
all Jrrightion M I TO D TE LIEA PLACEMENT METHOD&e1�1(j'UN�'Non-Water Supply Well: 'li/ fL 0ft /try'/f � 3 J 0
®Monitoring IJRecovery ft. ft //
Injection Well:
ft. ft
®Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
III Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
II Aquifer Test DStormwater Drainage ft. ft.
N Experimental Technology OSubsidence Control ft ft-
IIi Geothermal(Closed Loop) 'Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
'Geothermal(Heating/Cooling Return) al
(explain under#2I Remarks) ft ft.%
4.Date Well(s)Completed: ell ID# ft ft. f'•. ,
5a.W ll Location:
ft. ft. `--�..,Pa...,(v r^L it
SEP 2 0 6024
ft rt
Facilii� /Owner/ Name Facility ID#(if plicable) I fi J; „4:,i`(- 7.- 1 b
"6 L 7 Ca/ll e/liGi M./ sj ci�/'}� ft. ft. Ql It: 3 Ora
;rc;
�'t-L.�
Physical Address,City,and Zip ft ft.
r, MA a„
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County r � Parcel Identification No.(PIN) `l r ire/4- %'1�/(�
5b.Latitude/and longitude in degrees/minutes/seconds or decimal degrees: O r v t-ea r`-i/1 t Ca i^
(if well field,one lat/long is sufficient) 22.Ce ' lion.
N W TW2_-_2_0_1.
6.Is(are)the well(s) Permanent or •,,porary cure. C> ed a Contractor Date
By signing this form,I hereby certifythat the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: a}Yes or [jNo with 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known cell eonrtnrcbiaa hrfarmatiav 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. 1 ,
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 l GW-1 is needed. Indicate TOTALI3UMBER of wells construction details.You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /C5-0- (it-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(fdierent(example-3@200'and 2@I00) construction to the following: I,
10.Static water level below top of casing: 0 O (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing use"+" 1617 Marl Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 1p (in) 2411.For Injection Wells: Its 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: a (Jf l 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: eV�� 24c.For Water Supply&Infection Wells: In addition to sending the form to
nn the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: C .,/t Amount:_2., Cc^ S completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I ; Revised 2-22-2016
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