GW1--05686_Well Construction - GW1_20240920

Print Form,
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.Well Contractor Information: '
J2 ck TAVVIrt 07U ••14,WATER ZONES l ' ' '
Well Contractor Name FROM TO I DESCRIPTION
145 ? If G °►sp ft 9 7 it /GIP rvt
NC Well Contractor Certification Number /DO rL / I 0 t4 Gi>�m
15.OUTER CASING(for matt-eased wells).OR LINER(if ap 6cable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name O ft. l b ft. 4-1 in. cO.1 40 PVC
D f f� 16.INNER CASING INNG OR TUBING(geothermal)closed-loop)
2.Well Construction Permit#: Iv FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. I' in.
3.Well Use(check well use): ft ft in.
Water Supply Well: '^17:SCREEN
FROM TO DIAMETER 1 SLOT SIZE THICKNESS MATERIAL
®Agricultural QMunicipal/Public ft. ft. In.
iU Geothermal(Heating/Cooling Supply) Ei5esidential Water Supply(single) ft ft in.
III'Industrial/Commercial DResidential Water Supply(shared) IS.GROUT
I 'Irrigation FROM TO MATERIAL t EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. pO ft MEAT POt.gE p '/�'bs
I Monitoring Recovery ft. To ft.
�" fT
Injection Well:
ft. ft.
®Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
',Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL. ,EMPLACEMENT METHOD
®iAquifer Test IjStormwater Drainage ft ft
li Experimental Technology DSubsidence Control ft. ft
(.Geothermal(Closed Loop) °Tracer '20,DRILLING LOG(attach additional sheets if necessary) -
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
111 Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks)
ft. ft.
4.Date Well(s)Completed: 4-b"'21/ Well ID# ft ft.
5a.Well Location: ft ft.
ANr0OaJy Sivrr, QN ft. - 77 ..-.. 7....
Facility/Owner Name Facility m#(if applicable) ft ft g t`+...k.r' ... %Ir 1�L+1
aOA/ TbiscAMq DR. n. ft. SEP 2 Q [Q?R
Physical Address,City,and Zip ft. ft. ,
OR -f Irw:.1-4. rr eirr;i-_`y ,: r i tio.:',
An1G'it 21.REMr►RKS . ' _r... '"
D'A CellOG
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
. (if well field,one lat/long is sufficient) 22.Certification:
AS. a9 7 15 as N •V) .13 Sg 139 w /UGk ;s 8t-6"2q
6.Is(are)the well(s)0'ermanent or J Temporary Signature of Certified ell Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: )i Yes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out knoim noe11 coirc/ni"t/av 1a_,ri,,,matiaa aid 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 i GW-1 is needed.Indicate TMALI3UMBER of wells construction details.You may also attach ntitiitionalpages if necessary.
drilled: SUBMITTAL INSTRUCTIONS f
9.Total well depth below land surface: 3,40 _ at) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3#1200'and 2@I00) construction to the following: i
10.Static water level below top of casing: W (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
w VS - fill.) '
11.Borehole diameter: 24b.For Iajectiorr Ane11s: In addition to sending the form to the address in 24a
12.Well construction method: 4.'
,�0TAR., f above,also submit one copy of this form within 30 days of completion of well
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) 3 Method of test: PAM P 24c.For Water Supply&Inieetio'n'Wells: In addition to sending the form to
f� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: II TI Amount: i 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