GW1--06113_Well Construction - GW1_20241014

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: -
3Okft a'r4en
14.WATER ZONES i I
Well Contractor NameFROM TO DESCRIPTION
3o L( A7o ft. 75 f 5 &PKt
NC Well Contractor Certification Number p?81S`tt a5-0 ft !O GPiA.
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 it. C7a ft. /- Yq in. SD
p2 I Pu C -
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.) • d ft. 160 tt• y in. Sat
l (to p v_
3.Well Use(check well use): ft ft. in. •7�•
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
111 Agricultural (jMunicipal/Public ft. ft. in.
111 Geothermal(Heating/Cooling Supply) reesidential Water Supply(single) it. ft. in.
®Industrial/Commercial DResidential Water Supply(shared) - i
18.GROUT
I Irrigation FROM TO MATERIAL, ' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft. ga ft. s414l,ILA Pour 4 fn,� rel
*Monitoring jRecovery ft. ft. 1 OSO 165
Injection Well:
®Aquifer Recharge DGroundwater Rernediation 6 ft. 160 ft. A.>GCt'r Powr ?.boo 'bs 19.SAND/GRAVEL PACK(if applicable)
RiAquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Ili Aquifer Test I9Stormwater Drainage ft. ft.
III Experimental Technology QSubsidence Control ft. ft.
111 Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 1._I Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
d ft. c, it. a,, burden
4.Date Well(s)Completed: 1 l(-.2'4 Well ID# 0 ft. t 2 ft. Rea 1 c_f1Q�'
5a.WelLocation: 1.2 ft Olzb it. lj•�,/ Rot-
rw,a SeS S ft. ft.
Y l�L�-�:. �`
Facility/Owner Name Facility ID#(if applicable) ft. ft r `f 2,.,?,
ft. ft. , ucr 1 4 2024
Sa 3 N�,.4cr s.F. 4ccr � .271 I� ,
Physical Address,City,and Zip ft. ft. i G�`;' ,
�/��j rC A 21.REMARKS ;,•-"� `vx
•
County Parcel Identification No.(PIN) epactLe.)a 4e.r 105-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one lat/long is sufficient) 22.Ce 'II on
34).o7'738-172 N -7is.9ase0317 W ( .St2q4 g -/G/ •202H
6.Is(are)the well(s) Permanent or E3Temporary Si of Certified el ntractor Date
By signing this form,I hereby certifir that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or Ego with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known null 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. t
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.
drilled: I
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: pl(00 (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: 076- (ft) Division of Water Resources,•Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1f ,
11.Borehole diameter: v (in) 24b.For Injection Wells: In addition to sending the form to the address in 24a
4 1 above,also submit one copy of this form within 30 days of completion of well
CC 12.Well construction method: ' 4 try construction to the following: i
(i.e.auger,rotary,cable,direct push,etc.) II
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: r1 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) IC) Method of test: ( IOf.5e, 20 A'4 n 24e.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: Aril Amount: fa a Z 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