GW1--05706_Well Construction - GW1_20240920

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'Print Forrn,_..
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: '
.r.'c Cn .7,14::WATER'-ZONES .•' , , , __ • .
Well Contractor Name FROM TO DESCRIPTION
g77P ft, u tr. c�
NC Well Contractor Certification Number `e�f n 1 S�t� Ot� P M
41510IITER'CASING(for-inniti-eased"well's)OR'LINER Wan livable)"-' ,,_
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
CompanyName CD ft. yO ft. t t in- 5b R ai Pic
,16.INNER CASING OR TUBING(geothermal closed loop)" --..a
.2.Well Construction Permit#: FROM TO DIAMETER THICKNESSr MATERIAL+
List all applicable well construction permits(i.e.UIC.County,State.Variance,etc.) 4 ft• I I(a ft. y I' in- Sell '�1 o p i/c
3.Well Use(check well use): ft' ft. in.
)17fSCREEN ``-,, ,N •,:
I Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R. ft. in.
Industrial/Commercial DResidential Water Supply(shared) -181 GROUT ,• :'_
'
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. C.,O ft. �� 3/� Qn ',�� !�S
Monitoring Recovery v ft. f l` ft ,�/��r P f21 3515 fib$
Injection Well: 1 •
ft. ft. ,
Aquifer Recharge Groundwater Remediation
"19.SAND/GRAVEL-PACK(if applicable) ,
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD f
Aquifer Test QStormwater Drainage ft. R
Experimental Technology
(i )Subsidence Control ft. ft.
r
Geothermal(Closed Loop) O Tracet I g,28:DRII.LiNGIAG(attach additional:A 'vita if necessary)-;I: _:°
FROM TO DESCRIPTION(color,hardness soil/rock(Heating/Cooling Return) Other(explain under#21 Remarks)
soil/rock type grain sue etc.)
++ e o ft- a ft- 6ve t,c,t rde )
1 4.Date Well(s)Completed: -1- -eat LI Well ID# e2 67 ft. 3 ft- San do
5a.Wei Location: � ft- !Ll63 ft- Coley Q0Cie:_,,.,.,,•--;,. fT.-,�..h
Cft. ft. l t w- a..._ +! i:.—ZL.,
Facility/Owner Nime Facility 0)9(if applicable) ft. ft. s 1-lj „ 0 7024
H3o C a:-�-kn PonrJ LcCutsri I•,c.t rq ft. ft. A •
ft. ft. Ir,i:.:7.i:t;r.,: t'•' e4:-..7it fit
Physical Address,City,and Zip ,F .or
==/21,REMARKS=.'- - ii..:' S ! cr u =1:=
Frnflhl;n
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: n e/
3 ��SoZaf�CO N —7603L14fo�q W G� ''y6-?7 A i- /- c5
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certibr that the well(s)was(were)constructed in accordance
t 4.;},7 Is this a repair to an existing well: JYes or No with 15A NCAC 02C.0100 or 1SANCAC 02C.0200 Well Construction Standards and that a
�-=` 7,`ir- copyof this record has been provided to the well owner.
'.,a" 'Ifthis is a repair,Jill out known well construction information and explain the nature oftl:e
• 11 y'repair under#2I remarks section or on the back of this form.
1J ;ar,, K. a 23.Site diagram or additional well details:
'' ur =(+�a: "�'or'r You may use the back of this page to provide additional well site details or well
n %=K;•-8 For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
.:of-•#rconstruction details. You may also attach additional pages if necessary.
:,; }�:rT�eott�tiuctton,only 1 GW-1 is needed. Indicate TOTALNUMBER of wells
.drille�: SUBMITTAL INSTRUCTIONS .
9.Total well depth below land surface: 9 6 (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 a()1 00'and 22��@l00') construction to the following.
10.Static water level below top of casing: v(d (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing use"4-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (1) 1 (in) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Q above,also submit one copy of this form'witflin 30 days of completion of well
12.Well construction method: ' I•r 2OI-c r 1 construction to the following: i, - u
(ie.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) .R C) Method of test:R i locJ(1 c )PI;-1-1 24c.For Water Supply&Injection Wells: In addition to sending the form to
( 'l s�! the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 4 1-11 Amount: .oc I ()a 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