GW1--06746_Well Construction - GW1_20241112

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.P. 1ee-
1 Contractor `J
�CV 14:WATER ZONES
Well Contractor Name oM To DESCRIPTION
, LK/lri"f ft. Cited ft. a9
•J ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-eased wells)OR LINER(if ap licable)
Water Wizards Inc FROS j TO DIAMETER THICKNESS MATERIAL •
Company Name v ft' .04 ft' LI in' ' it Ala PVC
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.f11C,County,State,Variance,etc.) ft. ft, in.
3.Well Use(check well use): ft' ft. in
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) Dittscntial Water Supply(single) ft, ft in.
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
Irrigation FROM t TO MATERIAL -EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 0-ft. Ii — /4 ,1 Ee f/C396J65-
ram_
Monitoring Ovcry ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL • EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft• ft•
Experimental Technology 0Subsidence Control ft. ft.
Geothermal.(Closed Loop) E3Tracer 1 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ',Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type grain size etc.)
/�J�,� ft ft.
Date Well(s)Completed: /O'"/Well IDA ft. ft. k" '.( ,'s-_' '..I 9
5a Well Location• ft. ft.
,6ri Voe) ft. ft. Nov 1 2, t024
acilny/Owner Name Facility 1Dbb(if applicable) ff. ft. ^
(44 k;0 wbvS I4 h ft. ft. �;.V_
ftPhysical Address,City,and Zip i'
21.REMARKS
rV� s "E� $� / /�� I
County Parcel Identification No.(PIN) _r`"- l l..e4 '1 1 'Pr,r I'.1. 'u.99
5b.Latitude and longitude in degreesdnlnutes/seconds or decimal degrees: C-.V"SC....t AO
(iffwell fiel one la�llon is sufficient) / _n 22.Certification:
6.Is(are)the well(s)Et ermanent or [:)Temporary
Signature of rti1fiedWellConRIctor, Date
By signing this form,I hereby cerfio,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: .es ar O1 No with 15A NCAC Q2C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out/atoms mill ea,vtr«.,'vminfrmmugure. t,Rwaniemgb't ca9vof this retard has beenprovidedtothe well Digger-
repair under#21 remark section or on the back ofthis 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 TOTALI3UMBER of wells construction details.You may alsti,attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
vt/
9.Total well depth below land surface: OD (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdderent(example-3@200'and 2@l00) construction to the following:
an
10.Static water level below top of casing: e� (ft-) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
• 11.Borehole diameter: (in.) 2-0b For Infection.Welts: le�ition 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: K construction to the following.
(i.e.auger,rotary,cable,direct push,etc.) .
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) k Method of test: �� 24c For Water Supply&Iniection Wells: In addition to sending the form to
�f j/1, the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:.� / /4- Amount: f OCL t..4l'S 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