GW1--05699_Well Construction - GW1_20240920

Print Form '1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1. ell Contractor Information:
"D
14.WATER ZONES 1
FROM TO DESCRIPTION
Well Co _ etor Name q3 ft.
Cq ft l^
ft. ft. �, i r1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Wizards Inc FROM ell': ft.
DIAMETER , TRIMNESS
MATERIAL
Company Name 0 ft' l� ft. LI 1 in. SO&4 f
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. R. in-
3.Well Use(check well use): ft. ft. 1n.
Water Supply Well: 11.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
®Agricultural QM .'cipal/Public ft. ft. In.
■Geothermal(Heating/Cooling Supply) iji.Residential Water Supply(single) ft, ft. in.
III Industrial/Commercial DResidential Water Supply(shared) 18.GROUT /hDr
I Irrigation FROM TO I MATERIAL E�j LA ( M1OUN
T
{/,C
Non-Water Supply Well: 0 ft. ft- Veo- ' Coa.
"Monitoring iti Recovery ft. ft.
Injection Well: ft.
®Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
®i Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
llil Aquifer Test IDStormwater Drainage ft ft. j
is Experimental Technology I0Subsidence Control ft. ft.
I Geothermal(Closed Loop) jTracer 20.DRILLING LOG(attach additional sheets if necessary) . . ..
Geothermal(Heating/Cooling Return) fI Other(explain under#21 Remarks)j FROM TO DESCRIPTION(color,hardness soil/rock type grain size eta) '
ft. ft.
4.Date Wells)Completed: 61011Well ID# ft. ft. �-^ r%• .�`,
5a.Well Location: ft. ft. ` `�-�.1� ..
/^ SEP
t �'
�121/10 V ft. ft. SC P 2 Q 2V24
Facility/Owner Name Facility IDt#(if applicable)
ft. ft.
CI C ) ke.i � ft. ft. L,:v:^i;TaF'n t�Frr •
Ph ical Address,City,and Zip ft. ft. Q.`�.a vv
is O)p(e 21.REMARKS C- / 1.
County b L` Parcel Identification No.(PIN) ��,,�'5,t�Y�i/.j ;) ltt..2T (Qs /47
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: C+-�� V �1 1
(if well field,one IaVlong is sufficient) 22.Certification:
36 dr° N -`*74 �b q(M"', W 973a/w2k
6.Is(are)the wells) ermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certi&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or ONo with 1 SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out know?well coastrartkw krforwatio o cud erplatx me 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 OW-1 is needed.Indicate TUT AL NUMBER of wells construction details.You may also attach additional pages if necessary.
drilled: i SUBMITTAL INSTRUCTIONS,
i
9.Total well depth below land surface: �vOJ (it.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths((different(example.3@200'and 2Q100) construction to the following: I
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use' eee 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: I (in) 24b For Infection Wells: In addition to residing the form to the address in 24a
r� �r/ above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: r construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) 1
Division of Water Resources,)Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 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: frf4.14. Amount: completion of well construction Ito 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