GW1--06732_Well Construction - GW1_20241112

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I _ .P__u.__
1. 11 Contractor Information:
14.WATER ZONES
Well Contractor Name FROM /TO DESCRRPTION
P / � de a ft' '-trap
l� /��� C� ft. ft.
NC Wed Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Wizards Inc FROM TO DIAMETER THICKNESS M TERIAL
Company Name () ft. w ft. d
in. '�ft cfo' v6
V�l 2�-oag3 16.INNER CASING OR TUBING(geothermallccloosed-loo`pp)) !C�
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(l e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft 1°'
Water Supply Well: 17.SCREEN
FROM M TO DIAMETER SLOT SIZE ,THICKNESS MATERIAL
®Agricultural Municipal/Public ft. ft. in.
1 Geothermal(Heating/Cooling Supply) ali,esidential Water Supply(single) ft. ft. in.
1111 Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
is Irrigation FROM ' TO ' MATERIAL i EMPLACEMENT D OD&AMOUNT
Non-Water Supply Well: / eft- ft. A e' 1Q ,d7e/'yl65
M Monitoring Recovery ft. It. 11/ "`�e�
Injection Well:
ft. ft.
N Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
•Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
III Aquifer Test {jStormwater Drainage ft. ft.
NI Experimental Technology jSubsidence Control ft. ft.
1'Geothermal(Closed Loop) OTracec 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rack type,grain size,etc.)
is Geothermal(Heating/Cooling U�Rfeturrnn)Q� % Other(explain under#21 Remarks) fft.4.Date Well(s) / /Oa-1/�Completed: ( Well ID# ft. ft.
5a.WellLocation: ft. ft. 4 ...'k,-f., :r k..,1 4'
C0-0 h V�'err ft. ft.
Facility/Owner Name � Facility IDP(if applicable) ft. ft.
NOV 1 2 2024
C®ql/lYer WO�'.'r !w! c✓f cote_ cApvek ft. ft.
J Ir.f3 '_%.,:!
Physical Address,City,and Zip ft ft. L.;:�'.4_:_:
21.REMARKS / ,,
County v� Parcel Identification No.(PIN) �1� `•,%Y ICJ r- t'�.t7-et)rn
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: v 5-v'
(if well field,one lat/long is sufficient) / /r J j 22,C 'cation: ,,,�,(�� . /t
l . -1"1"1"t6 N- .l,J�2"T_`'7 Q W e-s- V'� ti . v
6.Is(are)the well(s)MI'ermanent or )]Temporary Signature of Certified Well Contractor I Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: g es or ))No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ijthis is a repair,fill out knout?well conshactisw informrtiom amd 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 1 OW-1 is needed. Indicate TOTALNUMBER of wells construction details.You.tray also attach additional pages if necessary.
drilled: t SUBMITTAL INSTRUCTIONS i •
9.Total well depth below land surface: 16I9 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifditierent(example-3@200'andi 2@l00') construction to the following: l'
10.Static water level below top of casing: 2LJ/ (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+i' 1617 Mail Service renter,Raleigh,NC 27699-1617
11.Borehole diameter: ��� (in) 24b.For Injection Wells: in addition to sending the fowl to the address in 24a
,(� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: UNIN construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER(gpm) 1 -L�SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m Method of test: 24c.For Water Supply&Infection Wells: In addition to sending the form to
r 1 ,( the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: /+ '/ 1`1 Amount: �� 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 Resource ; Revised 2-22-2016
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