GW1--06596_Well Construction - GW1_20241112

Print Form. ;,�
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: 1
t1 14:WATER ZONES
Well Con or Name FROM ToP. DESCRIPTION
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap cable)
Water Wizards Inc ' FROM TO DIAMETER THICKNESS
Company Nam 0 It. (#3 IL !. I, 21 i V6
36.TNNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 30 t"'7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,,Variance etc.) R- ft- in.
3.Well Use(check well use): ' ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural °Municipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) E5Residential Water Supply(single) R. ft In.
Industrial/Commercial °i Residential Water Supply(shared) 18.GROUT
Irrigation PROM ' /TO 1 MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft 11I) ft lei iide.Piet Peurzeci ' liydpi¢itt -MIAs
Monitoring °Recovery ft. ft
Injection Well:
ft. ft
Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test (DStormwater Drainage ft. ft. I.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary) .
Geothermal(Heating/Cooling Return) �I Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
q *1�� c�rcl ft cl.6 ft- nvZt�h�lls_ ti
4.Date Well(s)Completed: ,V'"1/ 'v-f Well LD# II 0 ft Q,,t>O R' f l Fit)/ hive G Mq 41+e
Sa.Well Location: 0_I.p ft' 126,d IL t line. G A.Adri
ik11ay C 4,)e. , _ - . .. y W 1
Facility/Owner Name Facility 1D9(if applicable) ft. ft. '�-"• t {
35 Lock hAVeil Ljor p spict lid1 ISC a731y ft. ft. IJ()V 1 2024
Physical Address,City,and Zip /_ M ft. ft. v
1.AStoti 1 01 i 1p 07g 21.REMARKS i1"::�,.. y ;
County • Parcel IdentificationNo.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees: •
(ifwell field,one lat/lon
g is sufficient) 22.Certification:
6,32.3`)9.2 N 75,alf13$' W 1 11-C124 1
6.Is(are)the well(s) Permanent or �I Temporary sigoanttc of Well ContractorDate
By signing this form,1 hereby cart fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DI Yes or ri5No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out knawn Hell conshactiaa information and explain Menature elate 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 TOTALNUMBER of wells construction&tails.You may also anach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS;
9.Total well depth below land surface: 120.01 (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(a 100) construction to the following: '
10.Static water level below top of casing: 3 6 r 0' (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: I r7 (in) 24b.For Injection Wells: In addition to sending the form to the address in 24a
,��e above,also submit one copy of this form within 30 days of completion of well
aO 12.Well construction method: !fi construction to the following: 1
(i.e.auger,rotary,cable,direct push,etc.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) a Method of test: I((- 24c For Water Simply&Injection Wells: In addition to sending the form to
/� the address(es) above, also submit one copy of this form within 30 days of
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13b.Disinfection type: 'Tf / Amount: b O.4,41, el 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