GW1--06731_Well Construction - GW1_20241112

Print Form^•
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.W ll Contractor Information:
/0`1 •ae/ '3c6I1\7q3r .
14.WATER ZONES i i
Well Contractor rName OM TO i DESCRIPTION
ti Ci J �'— e/ .60f4 ft. ,06U" Cff6fivl
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Wizards inc FROM TO DIJITER THICKNESS MATERIAL
Company Name
V ft. l OD ft I.
. 1/U �-
16.INNER CASING OR TUBING(Reotbermal closed-loop)
2.Well Construction Permit it:: W 2_ r 0 2111Q FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC.County,State,Variance,etc.) fL ft. is
3.Well Use(check well use): ft ft. i°
Water Supply Well: 17.SCREEN I',
FROM TO DIAMETER •SLOT SIZE THICKNESS MATERIAL
( Agricultural 0Mun cipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) g6sidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
Irrigation FROM TO ' MATERIAL L E!PLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Oft VA/9Q ft /' J�Jo p.r .cD J15
Monitoring ecovery ft LJ ft t
Injection Well: I ,,
It. t
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery �I Salinity Barrier FROM TO MATERIAL • EMPLACEMENT METHOD r
Aquifer Test (Stormwater Drainage ft. ff.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) nether(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type,grain size,etc.)
�'// ft. ft.
4.Date Well(s)Completed: 11 !f?L Well ID# ft. • ft i.. o
4 ., I
Sa WellLocation: ft ft
I444
,�f Aft(y ft ft NOV 1 2 [UZ4
Facility/Owner Name Facility lD#(if applicable) ft. ft
el q U I U 14irildr,✓ ador-d ft. - ft. L'.il'1,,; Cr 3
Physical Address,City,and Zip
ft. ft.
/(-0- • /)/ 21�REMARRKKS ° .
County L) Parcel Identification No.(PIN) .l ' f tJ`/ / d13kr I 09-1-4-,31
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: C. �' V
i.
(' well elldd,one latRon is sufficient) 22.Certification:o J
e9 )4 311 N / q l?qo q,7Cf W 11 �'/,r _ �' ��� i/ 7/09-61
6.Is(are)the well(s)pir• u anent or )I Temporary Signature of Certified Well Contractor i! Date
By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: es or ONo with ISA NCAC 02C.0100 or ISA NC AC'02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well 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 fo nt.
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 details.You.may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
/
9.Total well depth below land surface: t2(st Q (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
rat(10.Static water level below top of casing: rs� 1 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use/"'+'f 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ('' {m)
24b:For Infection Wells: In addition to sanding the fonu to the address in 24a
12.Well construction method: 'd
( „y above,also submit one copy of this.form within 30 days of completion of well
construction to the following: I
(i.e.auger,rotary,cable,direct push,etc.) r
Division of Water Resources,i'Uaderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) cd Method of test: 24c.For Water Supply&Iniection Wells: In addition to sending the form to
(( the address(es) above, also submit'one copy of this form within 30 days of
113h.Disinfection type: /.l j I' Amount: completion of well construction to the county health department of the county
where constructed.
I i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016