GW1--05700_Well Construction - GW1_20240920

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
t(`t.c. COO L 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
66 fL 420
"' P P,�
LIS 77 A 76 m IS" ft. 6 GMT edPrvi
NC Well Contractor� / Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Wizards izards Inc FROM TO DIAMETER I THICKNESS MATERIAL
Company Name 0 ft. L `j ft. O_ N I in• s®R e1 Q P v�,
16.INNER CASING OR TUBING(geothermal closed-loop)loo _
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) • ft. ft. 1 in.
3.Well Use(check well use): ft. It. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER. SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 0 ft• fL in.;
Geothermal(Heating/Cooling Supply) Egesidential Water Supply(single) ft. - ft. in.'
Industrial/Commercial OResidential Water Supply(shared) ,18.GROUT' -
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 ft. &I-) ft. 34 14d k pI, Poa re i . �,- �^ rr'1
Monitoring Recovery ft. ft. 1 a`
Injection Well:
'Ia
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery D Salinity Bather FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DiStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness wil/roek type,tam size,eta)
40
® 0 ft. tc2 ft. lam-�yt:r rr,e el4.Date Well(s)Completed: l"6 't��i Well ID# A ft. C,4a ft. Q C la O
9. /
5a.Well Location: . ft. tiro ft. 6sr y 2.oc.k
I .4o Ciarl� ft. ft.
FacilityRwner Namem Facility ID#(if applicable) ft. ft. �-. - y
'Siff C.L r10� 5540 G l (Za ft. ft. �w..,...e..v. 1-. wt
y�
Physical Address,City,and Zip ft. ft. S F P g 0 „U2 A
G nv r I'e 21.REMARKS G
o:m-'
County Parcel Identification No.(PIN) r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Lit/long is sufficient) 22.Certification:
36aas(a2.0d1 N 76 ci7 to.g NYC' W ��7_7 4 9-4me241
6.Is(are)the well(s)Ekermanent or Temporary
Signature of Ce Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
. 7.Is this a repair to an existing well: ['Yes or ENo with 15A NCAC 02C.0100 or 15A NCAC 02C A200 Well Construction Standards and that a
If this is a repair,fill out known well construction information 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.
23.Site diagralu 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. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface: I VC) (ft.) 24a.For All Wells: Submit this form,within 30 days of completion of well
For multiple wells list all depths if different(example-3Q2200'and 2(4 00) construction to the following: ; k
10.Static water level below top of casing: AS- (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
oo-- ( i�
11.Borehole diameter:
to �� (in-) 24b.For Injection Wells: In addition to sending the form to the address in 24a
�� �� above,also submit one copy of t1Lis form within 30 days of completion of well
12.Well construction method:A..r 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) V.
Method of test:ta p rap Aim 24c.For Water Supply&Injection Wells: In addition to sending the form to
pp� the address(es) above, also submit:one copy of this form within 30 days of
t`�r 13b.Disinfection type: n4 Amount: r 0 Z. completion of well construction to the county health department of the county
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources s Revised 2-22-2016