GW1--06057_Well Construction - GW1_20241011

a . Print Form.;..,,,,d
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1. ell Contractor Information:
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14:WATER ZONES s ,
FROM TO DESCRIPIIO
Well Contractor Name I3 I
CiUSYiC 71 ft. —7aft. p!w.
ft ft 1l
NC Well Contractor Certification Number i 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Wizards Inc FROM TO,�, DIAMETER: : THICKNESS MATERIAL
in
Company Name ® ft / 4 ft. (/ lid' g'( (//j /J
ri`w '^P 2� 16.INNER CASING OR TIMING(geothermal closed-loop) L
2.Well Construction Permit#: C•��J 9Vl E`ll FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft R• !in.
ft
3.Well Use(check well use): N in.
Water Supply :17.SCREEN
Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
a •F"cultural QMunicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) ' esidential Water Supply(single) ft ft. in.
%Industrial/Commercial QResidential Water Supply(shared) 18.GROUT
rIrrigation FROM t TO ' MATERIAL t EMPLACEM METHOD AMOpNT
Non-Water Supply Well: 0 ft. di(ft- N CAI p_I'.3 1/
I Monitoring fig 'ecovery ft. ft.
Injection Well: • ft. ft.
11 Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
*I Aquifer Storage and Recovery rI Salinity Barrier . FROM TO MATERIAL , EMPLACEMENT METHOD .
0i Aquifer Test 0Stormwater Drainage ft ft.
al Experimental Technology IDSubsidence Control ft. ft.
Geothermal(Closed Loop) l°.Tracer 'Zit DRII:LING_LOG(attach additional sheets if necessary) . ' - . ,
il Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sail/rock type,grain size,etc.)
/��cf ft. ft 1
4.Date Well(s)Completed: el/1 3 2' I Weil IDit ft' R' ;%1C�,,,`tea
Sa.Well Location: R ft ,'t ' . -,{.,,
�e� .e i4 ft. ft OCT _ 20
Faaacciijiliityy///Owne Na a /l�/� /J)/FaccilitityyIID#(if applicable)lable ft. ft. !V v '/T'„`l'''
.1 24
ich1 " ' C,0 "r`- V C e1C Md 'J 00\ --�!( ft ft. h7n,:3-,-,"r':.�,,'•i i!'^:.
L.� ft ff. , —1.,,,,„,t_;j
Physical Address,9 City,and Zip i
Al a fr e...,- 21.REMARKS{ �/� g(gel
p ,,_ e
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County Parcel Identification No.(PIN) g e if)-
r 4rc/ Jj
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: --I
Aal
(if wellfield,on lat/lon is sufficient) (� 22.C :cation: n��
t{�®��7ACgNd �q°toil 7.I� �( w � 01 /e �"l
6.Is(are)the well(s)�;' manent or �l Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certfy that the well(s)was(were)constructed in accordance
7.Is this a repair to au evicting well: M es or ONo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known,NW,evwstemderinyCa YiarandereltsirRreensaterroftke copy of this record has beenprovided 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 GW-]is needed.Indicate TOTALNUMBER of wells construction details.You may also attack additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ¶ 00 (fk) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if-different(example-3@200'and 21la 100) construction to the following:
10.Static water level below top of casing: e�1/ (ft.) Division of Water Resources,Information Processing Unit
II-water level is above casing,use/+? 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (..7 ''ef {in.) 24b:For Itrjeeirete Wells: in addition to sending the fort to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: ���>`�// construction to the following: '
(Le.auger,rotary,cable,direct push,etc.) f
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1
13a.Yield(gpm) 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: /4" YJ Amount: 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 Resources4 , Revised 2-22-2016