GW1--06733_Well Construction - GW1_20241112

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i Print Form_
WELL CONSTRUCTION RECORD (GW-1) ' For Internal Use Only: •
1.Well Contractor Information:
J Ray aleizbtn '14.WATER ZONES t I
Well Contractor Name FROM TO I DESCRIPTION
a�ya - A Igo ft. IBS . -ZDCri l
NC Well Contractor Certification Number • 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)'
Water Wizards Inc FROM TO DIAMETER• �T,HIICKNESS I n MATERIAL
10 ft. 03 ft. C ✓Vf M.I r2, 1'
Company Name 2.Well Construction Permit#: I/"��/ ` v V J 1,^� a 16.INNER CASING OR TUBING(geothermal closed-loop)
r FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.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
a Agricultural fDMunicipal/Public ft. ft. in.
N Geothermal(Heating/Cooling Supply) r,Residential Water Supply(single) ft. ft. in.;
I Industrial/Commercial DResidential Water Supply(shared) I8.GROUT
Irrigation FROM I TO 1 MATERIAL -EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O I' 93 ft. 16 JJt•Ph,r POtiltii{I IlyAgA-iil 7( Ib5
II Monitoring I3Recovery ft. ft.
Injection Well: ft. , tL
111 Aquifer RechargeGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable) •\
i�I Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
•Aquifer Test DStormwater Drainage ft. ft. I2
II Experimental Technology jSubsidence Control ft. ft. 1•
4 Geothermal(Closed Loop) °Tracer ' 20.DRILLING LOG(attach additional'sheets If necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,de.)
it Geothermal(Heating/Cooling Return) Other(explain under#2I Remarks)
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yy{�{++►► 0 it' I 0D' OL)t�6uA t N •
4.Date Well(s)Completed:/O-q-.z gWell ID# i 10 ft' 16 fL ggt lad S 3.A It
5af._Well Location: 7 8 il3 tc V Iut- ' C r-41.;t_
Lil fl Al t:Z. 46a t 5vIJ �• � rti .O0 �j 4.�• i`A n►�t 4 C... :'2.-
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ft.
Facility/Owner Name Facility m#(if applicable) ft. D' ' " r �" '.4 , tr i!„ L F
a59L) I\c6.acor I-N Elillsbottot,t911 t1 .2-0.-7 8 ft. n Nf1V 1 s 2024
Phhyysical,Address,City,and Zip q(}pI, �/ ft. ft _
1 kacie, JQ 1lX Irid'7e 21.REMARKS •
County - Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: .
3&,121P2.010 N -1 .02.gSI5-9 W
----r,- 1-11-44.4..• ..
ic..,-,..it
6.Is(are)the well(s)fi Permanent or ]Temporary Signature of C led well Contractor Date
By signing this form,I hereby certjfr that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or QNo with 15A NCAC 02C-0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this it a repair fill out knows,urn cwrstiachi»r4 .,...t:.,.ow)erp+4rivr tketratzreofthe copy of this record hes beenprovided to the well owner-
repair under#2I remarks section or on the back of this form.
23.Site diagram or additional well details:
S.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 attack additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ....L0 0 a D (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100) construction to the following: i•
1 i
10.Static water level below top of casing: 5+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 1 I (con.) 241r.For Irticcti,ar Wells: la additimo¢to sending the form to the address in 24a
1 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Q 1 I'I construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) f
v Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,'Raleigh,NC 27699-1636
Q, ,,, .'I ty, ,1 4
13a.Yield(gpm) 0 Method of test 8L. IL JI'� Pa iv 1�4c.For Water Supply&Injection Wells: In addition to sending the form to
l l /� the address(es) above, also submit the l copy of this form within 30 days of
13b.Disinfection type: Amount: I N 2. 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 i Revised 2-22-2016
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