GW1--06734_Well Construction - GW1_20241112

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I
1.W. Contractor Information:
""` � ird,
+`I4.WATER ZONES
Well Contractor Name 'F'"ROOM TO DFSCRIP,TION
' _I J ft, ft.
NC Well Contractor Certification Number , 15.OUTER CASING(for multi-cased!wells)OR LINER(if an licable)
Water Wizards Inc FROM TO DIAMETER THICKNESS Pvc
ERIAL
Company Name U ft. (.f/ O [t. (,.i in. At CIO
` -,�� SS I6.INNERCASINGORTUBING'(geothermal+c`l'osedd-loopf
2.Well Construction Permit#: w FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(I.e.UIC,County,State,Variance,etc.) ft. 8.
3.Well Use(check well use): ft m
Water Supply Well: „17.SCREEN i
FROM" TO DIAMETER SLOT SIZE THICKNESS MATERIAL
(U Agricultural Muni ' al/Public ft. ft. In.,
it Geothermal(Heating/Cooling Supply) ; esidential Water Supply(single) ft. ft. - . in-
ig Industrial/Commercial DI Residential Water Supply(shared) 18.GROUT I. - •
Irrigation FROM O IA' MATERIAL E LA MI OD&AMOUNT
Non-Water Supply Well: 0 ft. +fig ft. Weed-e<j tnp 'Sow-165
a Monitoring Query ft. ft.
Injection Well: .
ft. ft. (
U Aquifer Recharge DGroundwater Remediation
� 19.SAND/GRAVEL PACK(if applicable) -"',i q
1.J)
MI Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
(U Aquifer Test 0 Stormwater Drainage ft. ft- 1
fU Experimental Technology DSubsidence Control ft. ft. ,
Illi Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)..• , , a,
ill Geothermal(Heating/Cooling Return) )Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type grain sue etc.)ft.
ft. It
4.Date Well(s)Completed:if44.121 Well ID# ft. ft. I
5a.Well Location: ft. ft (.. i ,._.
>
ft, ft ii
Facility/Owner Name Facility ID#(if applicable) ft, ft 'V U y 1 2 2074
c6,3 •c--eery. �. ft. ft.
Physical Address,City,and Zip ft. ft. ' -..
��`-'''}}^ 21. MARKS' (el' li: /+,,, ,,
County` Parcel IdentificationNo.(PIN) _ • `,1 1 ` '; Cam'^^-'.i
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: e....0- in1
(if well field,one 1aUlong is sufficient) 22.Certification:
36°to'ct5'1LQ ?go 7 'e-l7, W iCe(1 `17/iriay
6.Is(are)the wells) T ermanent or alTemporary Signs of Certified well Contractor 1 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: ' es airgr or QNo with 15A NCAC 02C_0100 or 15A NCAC 02C-0200 Well Construction Standards and that a
If this is a repair,fill out known mood coesimeticw infuweation and explain the natare 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:
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 TOTALIWMBBR of wells construction details.You may also attach,additional pages if neaeecary.
drilled: SUBMITTAL INSTRUCTIONS I.
• 9.Total well depth below land surface: /,t (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: ;,
10.Static water level below top of casing: OL '1 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"s+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1" VI (in.) 24b.For iniectloo Wells: In addition to sending the form to the address in 24a
Q_ L ry above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: t�Jfi�f�( construction to the following:
(i.e.auger,rotary,cable,direct push,etc) I'
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: • 1636 Mail Service Center,Raleigh,NC 27699-1636
f
13a.Yield(gpm) Method of test: /t/�,h . 24c.For Water Supply&Iniection Wells: In addition to sending the form to
/ the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 4-I J Amount: 6 ,em.L..-8 completion of well construction tot the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 2-22-2016
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