GW1--06092_Well Construction - GW1_20241014

II
Print Form 1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1. ell Contractor Information:
11. 1
i(e _ �� ( 14.WATER ZONES
i
'V � FROM TO DESCRIPTION
Well Contractor Name C hV / O 1 (8)0
NC Well Contractor Certification Number , 15.OUTER CASING(for multi-cased wells)OR LINER(KM) licable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft-
Company Name 100 ft. q In. d o {2vC
Way' oast' 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc) ft• ft. is
3.Well Use(check well use): ft ft. in.
Water Supply Well: FROM�E TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agricultural OM .icipal/Public ft. ft In.
Geothermal(Heating/Cooling Supply) be Residential Water Supply(single) ft ft. is
Industrial/Commercial D1 Residential Water Supply(shared) 15.GROUT 1 ' 4
Irrigation . FROM TO ' MATERIAL I EliEWLACEMENT ME OD&AMOUNT
Non-Water Supply Well: 0 rt. (14'Q ft.
/,ae4 1p f'� /s C6'/(S
Monitoring Recovery it ft yV
i.
Injection Well: ft. ft.
Aquifer Recharge DI Groundwater Remediation 1
19.SAND/GRAVEL PACK(if applicable)
_ Aquifer Storage and Recovery oSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test oStormwater Drainage ft• ft 1
Experimental Technology OSubsidence Control ft. ft
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if neeeccary)
Geothermal(Heating/Cooling Return) fi Other(explain under#21 Remarks) ( FROM TO DESCRIPTION(color,hardness soil/rock type,grain size etc.)
/�,."`II ft ft.
4.Date Weil(s)Completed:10/3/t Well ID# ft. ft. r,''--.7 ; ''-`
fft t ,,:..- �...' 6.., +2.. 5 :)
5a.Well Location:
�5 vt Volt.._ ft. ft OCT 1 4 2024
Facility/Owner Name �f ' n/Facility 1D0(if applicable) ft' ft
t0!/isJ Orr fJ �G/ {Jl J* ft. ft. I I r:1,r a...e;: _, . ._ ,,. y Li. e,`:.
i
Physical Address,City,and Zip ft. ft.
0 a 21.REMAARKKS� ,,,/ J�
County Parcel Identification No.(PIN) DI'`�� '!1 t4\� ``/` t f'��'f'j
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Cif" -e ' \+
(if well field,one l Ulong is sufficient) / /(/ a22.C r.motion
6.Is(are)the well(s) ermanent or J]Te orary Signature of Certified Well Contractor Date
By signing this form,1 hereby cert�that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: es or C3No• with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this it a repair,fill out/gown NOmarinertimr i rfornratian and asp/air 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 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 OW-1 is needed.Indicate TCITALNUMBER of wells construction details.You may also attach additional pages if necessary.
I
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ! O (ft) 24a. For All Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depths ft-different(example- @200'and 2@100') construction to the following:
1
10.Static water level below top of casing: a (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ('m) 241i.For Injection Wells: In addition to sending the form to the address in 24a
I/J„��(�' above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: If y 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) / 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: 14 f 14 Amount: 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 Revised 2-22-2016
I
i
1