GW1--06112_Well Construction - GW1_20241014

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I - Print Form-- 1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.Well Contractor Information: ,
1
-Yoh,. 04 4ert 14.WATER ZONES i
Well Contractor Name FROM TO 1 DESCRIPTION!
3a a y -� ft.ROO ft. 165 ft 3o &Poi
ft
NC Well Contractor Certification Number 1 15.OUTER CASING(for multi-cased wells)OR LINER(if ap Ucable)
Water Wizards Inc FROM TO DIAMETER I I THICKNESS MATERIAL
Company Name O ft /_3 D. 6 '/q in.' SDR 07) FVC.
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) a it. to ft. ' in' Sc 140 Ric3.Well Use(check well use): ft ft to
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
IN Agricultural OMunicipal/Public ft. ft. tn.
111 Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in. I
r Industrial/Commercial DI Residential Water Supply(shared) IS.GROUT
litigation FROM TO MATERIAL No Et EMPLACEMENT ME�IOI i
ft t AMOUNT
Non-Water Supply Well: 0 3 n' 3 k Q' ilidcwie
fi Monitoring ORecovery ft: ft . F e.e 7So 165
Injection Well: �yt
Aquifer Recharge DI Groundwater Remediation 0 ft- fa ft. Ne A4' your a sb lbS
19.SAND/GRAVEL PACK(if applicable)
*Aquifer Storage and Recovery )I Salinity Barrier FROM TO MATERIAL' . EMPLACEMENT METHOD
(�IAquifer Test I�StormwaterDrainage ft I
II Experimental Technology Subsidence Control ft. ft.
1;Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color.hardness,soiUrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
r7 u Q O n t� n �C r b[.�r'e kn
4.Date Well(s)Completed: -S c l Well1D7� 4 l-_l ft. .i� ft / C(,..1(2)
�
5a.Wefl Location: sV I�0 ft vim gr `� �
Me.Ir ssa 0;e5c) ft. ft 1 +;�
Facility/Owner Name Facility ID1t(if applicable) tt ft y c ,r „v
7.
.26a Se,pP's:re Fa o-% Tel Ns4°J le, M:l1S 1t ft /r 9 �' ,j 4TM'
Physical Address,City,and Zip D' f. O IJ �'^� L 024
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21.REMARKS
Person IIr'v.1";1:.t:ri ,`..1', 1'
County Parcel Identification No.(PIN) fit,
5b.Latitude and longitude in degrees/ntinutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) Ce J.:time / !d 9 I(4-
34.agV3to2 N ,7g.oaabS.33 w
1-. q 7 A it-s-.2y
6.Is(are)the well(s) +Permanent or lTemporary Signature of Certified Well Contractor Date
By signing this form,1 hereby cert fy that:the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or Bro with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If Air is a repair,fill out know sit en+erlvueticAr kefor eetiar antie.rpkzbe the non:reefEke copy alibis record has been provided to tare well owner.
I.
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 TOTAL731.1MBER of wells construction details.You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ire) (ft.) 24a. For Ail Wells: Submit this fuurr within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following: I
10.Static water level below top of casing: c25' (ft) Division of Water Resources;Information Processing Unit,
Ifwater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
4 1
11.Borehole diameter: /I (iD) 24h.For Infection Wells: Ia additi :to sending the form to the address in 24a
/� nn above,also submit one copy of this foim within 30 days of completion of well
12.Well construction method: IICICor y construction to the following: I
(i.e.auger,rotary,cable,direct push,etc.) r Division of WateResources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: //�� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test:(Ibt tt c ►24c.For Water Supply&Iniectio f Wells: In addition to sending the form to
,,11 the address(es) above, also submit tone copy of this form within 30 days of
n 13b.Disinfection type: AT Amount: $ O Z., - completion of well construction to the
e�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