GW1--06064_Well Construction - GW1_20241011

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1
1.W Il Contractor Information: /
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IQ/ �oT L '14.WATER ZONES l 1
Well Contractor Nameam FROMTO I DESCRRIIPTTON
W 6 S -� OM ft. 7r /061:20,
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)we OR LINER(if ap licable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft 04 ft. Li I 'in. t r0`41 PVC16.INNER CASING OR TUBING(geothermalclosed-l000p)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft i in.
3.Well Use(check well use): it ft. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
®Agricultural OM icipal/Public ft. ft. in.
E Geothermal(Heating/Cooling Supply) 2,residential Water Supply(single) ft. ft. in.
K Industrial/Commercial DResidential Water Supply(shared) 18.GROUT -
I Irrigation FROM ' TO MATERIAL EMPLACEMENT METHOD&AMOU
Non-Water Supply Well: 0 ft 6—1 ft !�- Qti ,,,/ /•Soo Il
',Monitoring 2 Recovery f. ft . [r�w�i
Injection Well:
ft. ft
K Aquifer Recharge QGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
II Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
®rAquifer Test DStormwater Drainage ft. ft. 1,
iK Experimental Technology (Subsidence Control ft ft r
El Geothermal.(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
II (Heating/Cooling Return) 1 'AOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal -
ft ft. !'
4.Date Well(s)Completed: 5/OWiiJl l Well 1D# ft. ft'
5a eti Location: ft. ft f m
C� --r t ft. ft. ' ,�,.._ .
Facility/Owner Name Facility LOP(if applicable) ft ft. OCT 1 I ZU24
J �® ) � � ti�i� 1-C J ed /24 ft ft
Physical Address,City,and Zip ft. ft I; i,, ;-r, ,L
e7V I I tl p_ 21.REMARKS1� � �/,, �1 ��e
County rI l r/ Parcel Identification No.(PIN) ..VA"- f U�'4' 4 1't f/f 1 Cl/�wP
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Crki 1,
(if ell fiend,one lat/long iss ssuufficient) �J p, 22.Certification: ,,� �l ,/SC. —1 au31 1 N — /-X`7�ig`CCS w at., <4QvV'C � / r/.54
6.Is(are)the well(s) ermanent or (]Temporary Signature of Certified Well Contractor Date_
By signing this form,1 hereby certfy Oat the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: De or [ No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill outknowt well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#2I remarks section or on the back of thisform. 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-1 is needed. Indicate TOTALNUMBER of wells construction details.You may also attack additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS i;
9.Total well depth below land surface: "7 5- (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,200'and 2(0100) construction to the following:
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10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: �(ail,
24b.For Injection Wells: In addition to sending the form to the address in 24a
lee/ � above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following: I ;
(i.e.auger,rotary,cable,direct push,etc.)
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Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) j x+ Method of test cn_t 24c.For Water Supply&Injection Wells: In addition to sending the form to
T . the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: T Amount: U�-C completion of well construction tol the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016