GW1--06070_Well Construction - GW1_20241011

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Yoke% 4 4 4.en 14.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION
3oa�{ A i ft. 13o ft. ao I t!>P•i
it ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
Water Wizards Inc FROM TO DIAMETER' THICKNESS MATERIAL
Name 0 It 3 7 ft.
‘ Vi to S to d 1 a"Qv C.
"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. ft. in.
3.Well Use(check well use): ft. ft rO
Water Supply Well: 17.SCREEN
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agricultural IDMunicipal/Public ft, It. in.
Geothermal(Heating/Cooling Supply) EICsidential Water Supply(single) ft. ' ft. In.
Industrial/Commercial QResidential Water Supply(shared) 18.GROUT I
i_ Irrigation FROM TO n MATERI tt EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 37 ft *rN,oleek Po(sr 4 l4ydret4e. ir)
Monitoring DRecovery ft. ft. ; D /5 C) )b S
Injection Well: / (�
ft. ft.
Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery EjSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft' ft
Experimental Technology IJSubsidence Control ft. ft. I,
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
(Heating/Cooling Return) nOther(explain under#21 Remarks) ft a fL e�`, �
d
4.Date Well(s)Completed: CI' 'c q Well ID# aei' ft- 3o SejA/ •
Sa.Well Location: 30 ft- 1110 ft 5CiM 540".e
( Door l4o v e.S ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft' ft I
ft. ft. I 1'.�rp,0.."k..., °:rc(,"
$S i..heM� PoreS-- Or Petwikla ,, (ny ._ ,
Physical Address,City,and Zip a'7s�S- ft. ft OCT T = U
r�AU /1 21:REMARKS
County Parcel Identification No.(PIN) 1. •_.., , "'-- -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I `""' "' t
(if well field,one tat/long is sufficient) 22.Cl/don: '
34, to H -t 3C N • (09 74�'. 51�1 Yirir w -2._-Zc�
6.Is(are)the wells) ermanent or Temporary i tore of Certified II Contractor 1 Da'fe
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: )i Yes or !No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifehis is a repair,fill out known null constructioe infrerwevion and arplain eke 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. i
23.Site diagram or additional well details: •
8.For GeoprobelDPT 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.IndicateTOTAL131)1dBBR of wells construction details.You may also a..ach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I qo (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@2000n0'and 1@100') construction to the following:
1JI 10.Static water level below top of casing: S (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: I`b (in) 24b.For Injection Wells: In addition to sending the form to the address in 24a
1(
n Y above,also submit one copy of this form within 30 days of completion of well
12.Well constr action method:Are O r construction to the following: !
(ie.auger,rotary,cable,direct push,etc.)
. Division of Water Resources,iUnderground Injection Control Program,
FOR WATER SUPPLY
^^WELLS ONLY: `_ �L 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) p[C) .Method of test:a Qn tI)P 24c.For Water Supply&Inlec ion 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: lii14 Amount; 7 bZ 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
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