GW1--06105_Well Construction - GW1_20241014

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.W IIContractor Information:lopf-L
e S 0-v i; 14.WATER ZONES I
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Well Contractor/ Name' OM TO D CRIP•riON
14�167'V ft. ft. 640,1411 i
ft. ft 111
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased'wells)OR LINER(if appIlicable)
Water Wizards Inc FROM TO DIAMETER THICKNESS I MATERIAL
Company Name V fL ct5 ft. 1 i in. 5 0:06, gi •
16.INNER CASING DR TUBING(geothermal closed-loop)
`1, 2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
.,.;14,,, List all applicable well construction permits(i.e.UIC,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
®Agricultural 9M 'cipal/Public ft. ft. in.
R Geothermal(Heating/Cooling Supply) a, esidential Water Supply(single) ft. ft. in.
N Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
i Irrigation FROX TO MATERIAL . EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: V ft C(3 ft. tit , . -
..f&d/�5—o1(�
$Monitoringfecovery ft ft. t "
Injection Well: ft. ft. '
I®Aquifer Recharge QGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
*Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
III Aquifer Test IIStormwater Drainage ft ft. ,
$Experimental Technology IQSubsidence Control ft. ft. 1
"'Geothermal.(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type grain size etc.)
(Heating/Cooling Return) (Other(explain under#21 Remarks)Geothermal / () n n 1/� ft. ft.
4.Date Well(s)Completed: 'I.//t'/&'c1 Well ID# Any A- 3q ft. ft.
!- 7
5a %ell Location: f ,,r ft. ft +-- i. ' ' ,' i:�•.
leia-h/�C._I ft. ft. s.
Facility/O erName Facility ID>l(ifa plicable) ft. ft "CI- 1 [U2�
,/CI a ft. ft.
Physical Address,City,and Zip ft. ft D'i'c i,;; 1:;ti 4
6ers0A 21.RE
Cty Parcel Identification No.(PIN) �1-04[4 I l he t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36di 0i010 N -7407 351y7 W (4� ci\fveo2 /i(2k2q
6.Is(are)the well(s)VI!.' rmanent or ]Temporary Signature of Certified Well Contractor Date
i
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: alrteor DNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known w+e/I 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. 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 T(7TAL13UMBER of wells construction details.You may also attach additional pages if necessary.
drilled: (,�/) SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: `t/ (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@200'and
'2@100') construction to the following:
10.Static water level below top of casing: �`aJ (ft) Division of Water Resource's,Information Processing Unit,
If water level is above casing,use"+"l 1617 Mail Service Center,i Raleigh,NC 27699-1617
11.Borehole diameter: G (in.)
24b.For Injection Wells: In addition to sending the form to the address in 24a
�( above,also submit one copy of this form within 30 days of completion of well
12.Well 0 construction method: l`f construction to the following: 1
(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) d 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 1/ 14 Amount: C completion of well construction to the ci unty health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources 4 Revised 2-22-2016
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