GW1--06111_Well Construction - GW1_20241014

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Print Form i
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1. 'JWeelll�Coon(trraaccttoo�r Information: rjx/
14.WATER ZONES I
FROM TO DESCRIPTION'
Well Contractor Name
c-ftiSeG 10 ft. 16o ft '78pwl.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap ►icable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 690
ft. (,,i In. $Oa. G
6 eu
Company Name
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.
Water Supply Well: 17.SCREEN
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
iIl Agricultural QMunicipal/Public ft ft. In.
M Geothermal(Heating/Cooling Supply) ettesidential Water Supply(single) ft. ft. in.
M Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
I Irrigation FROM TO MATERIAL
� r I LMFLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Ui ft 6�(!i ft. L , Q��
M Monitoring overy ft. • ft /
Injection Well:
ft. ft.
a Aquifer Recharge )]Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
I Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
al i Aquifer Test I9Stormwater Drainage ft ft.
II Experimental Technology IOSubsidence Control ft. ft.
®!Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
•Geothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soi0rock type,grain size,eta)
ft. ft. •
7/Nj�-N TALI O- 131, ft. ft.
4.Date Well(s)Completed: Well ID#
5a.Well Location: ft. ft. _ .
i :aa
r` i po..r .94•z�.6,4- fft. ft f. OCT 1 2024
Facility/O er Name Facility ID#(if applicable)
Physical Address,City,and Zip ft. ft rr11 ' . "� 41f'
,fit / / �_J / �' 1. �1.i %r
P of 2L4i/ "tT eiL 2 1-test/ ` Or f-P-e- -iO3
County Parcel Identification No.(PIN) -� Q �JJ
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: C,`�
(if well field,one latnong is sufficient) 22.Certification:
3to a(--iil N N`-7c(,(19D 6-6 37 W 0/4-4/ s it `)/u/-K
6.Is(are)the well(s) ermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certifr that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 2es or DINo with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out kaoim null construct-4oez ixiarsstatioa 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 l GW-1 is needed.Indicate TOTALI3l)MBER of wells construction rl"tails.You may also attach additional pages if necessary.
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drilled: SUBMITTAL INSTRUCTIONS I
/9.Total well depth below land surface: (-9 d (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ff ddereut(example-3@200'and 2Q100) construction to the following: 1
10.Static water level below top of casing: p2 b (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Matt Service denier,Raleigh,NC 27699-1617
11.Borehole diameter: (y`"f (in) 24b.For Infection Wells: In additioa to sending the form to the address in 24a
t0 r IV/
V�j above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: F-5I r 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: j"iH' Amount: completion of well construction to the county health department of the county
where constructed. '1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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