GW1--06102_Well Construction - GW1_20241014

•
Print Form I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
i
1.Well Contractor Information: j
�h„ ( 14.. - -
WATER ZONES 'I
Well ConnactorName FROM ; TO DESCRIPTION '
300,41- � � /6 b /c ereol
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(If ap licable) ,r
Water Wizards Inc FROM TO DIAMETER I . THICKNESS MATERIAL V�t
P-' {_/
Company Name ft.
a `� ft- in !-j. �6 \`
®5WPr0007 y^n23 FROM CASINGOvORTUBING DIAMETER'ermalJIIloop) �J
2.Well Construction Permit#: /�(� TO ' THICKNESS MATERIAL
List all applicable well construction permits(Le.UlC.County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft' ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
la Agricultural DMunicipavPublic ft. ft, in.
a Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft - ft. in. ,
11 Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
I Irrigation FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: 0 ft 1r 3 -i�/�//./Cif(�� RAILCI 1w2 47Ci b)
a Monitoring E3Recovery © iti g 0 N- �Afe 1 PougEb 31.0IhS
Injection Well:
N Aquifer Recharge OGroundwatir Remediation
19.SAND/GRAVEL PACK(if applicable)
"'Aquifer Storage and Recovery DSalinity Bather FROM TO MATERIAL I EMPLACEMENT METHOD
SI Aquifer Test IDStormwater Drainage ft ft I
II Experimental Technology Subsidence Control ft. ft !.
I Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(tutor hardness soillrock type grain sva.etc.)
/- ft. ft. Lir6iderl .
q
4.Date Well(s)Completed: I-2-0 -2 hVel ID# ,4//' 62- 7 ft. l g ft. (,�,.f 5
5a.Well Location: 1 b fr. ISO A fey r:
RR y� -�,.�
Facility/Owner Name Roil' ID#(ifapplicable) ft ft q ,:+°Fj L. ; f++cj,T d1
5'7� ����5 rd. �� % /fs n( OCT 1 4; 2024
Physical Address,City,and Zip .Z754/
PC.(jr OS A. 21.REMARKS 11"J:++1.+i7-_1 '-. , ' ., t,..,
County Parcel Identification No.(P(PIN) C't c r O `'3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Ce " cati i,:
N W Air 3y s l D? 9.1-2102L
6.Is(are)the wells) rmanent or Temporary Signa of Certified We(4/2
• ".c" � Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: f Yes or OfC with I5A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain 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. I
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 TOTAL NUMBER of wells construction details.You may also attach additional pages if necessary.
wed: � SUBMTI TAL INSTRUCTIONS
9.Total well depth below land surface: 1 $ � (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2Qa 100) construction to the following:
i
10.Static water level below top of casing: ZC (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: COv in. I
( ) 24b.For Infection Wells: In addition to sending the form to the address in 24a
/f � above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 4 construction to the following:
(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
�J/J/ I'
13a.Yield(gpm) / C Method of test: /liJYt .G�/1✓": c.For Water Supply&Infection.Wells: In addition to sending the form to
p�( � the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: P- 1 / Amount: q/7L1 M G e 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