GW1--05874_Well Construction - GW1_20230912

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
1 lT Ck ----19'Y"1�.'s 6N 14.WATER ZONES . 1
Well Contractor Name FROM TO DESCRIPTION
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63fL 6 Ef / GIP AA
SS 1 fL it: GI Pm
NC Well Contractor�Certification '� � 'zit- D. '_`
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Wizards Inc FROM/[ TO DIAMETER� THICKNESS MATERIAL
CompanyName v ft. 120 fe '[1 ' " S'(A4-yo PVC
16.INNER CASING OR TUBING(geothermal dosed-loop)
Z.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL .
List all applicable well construction permits(Le.UIC,County;State,Variance,etc.) fL ft- in.
3.Well Use(check well use):
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
()Agricultural ()Municipa1/Public fL ft. is
()Geothermal(Heating/Cooling Supply) residential Water Supply(single) fL ft. in.
()Industtial/Commercial ()Residential Water Supply(shared) 18.GROUT
(Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 ft- GO n „►C QD-(�k 'fro nos
()Monitoring (()Recovery ft. ft- ' ! AGO
Injection Well:
It. ft.
Aquifer Recharge ()Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery ()Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ()Stormwater Drainage ft. ft
Experimental Technology ()Stilrsidence Control fL ft.
BGeothermal(Closed Loop) ()Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM ft. TOft.
N DESCRIPTION(color,hardness,sowroek type Wain size.etc.)
4.Date Well(s)Completed: (7 ^3-23 Well ID#A68/45 1 ft. ft. r.,.,7 I, -, ,E �
ft. fL t 6 b.....b.,r IL,$ ' 3
5a.Well Location:
ST> TItoR Jcu c ft. ft. SEP 1 2 2023
Facility/Owner Name Facility ID#(if applicable) ft, ft
67 Fannie Jones Rd Roxboro NC 27574 ft. ft. I ]niti:lsca;le71 r'rc.:�T•U;ts URA
Physical Address,City,and Zip ft. ft.
Person 21.REMARKS ,
County Panel Identification No.(PIN) PL4rtzvER TN Tor' tGTTRVc n-n-t Ct
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Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: w `.��G, '
(if well field,one lat./long is sufficient) 22.Certification:
3 C.14(V && 2 3 N s 7 S'I °12 13 `I W N aHrr cow t-3-.2 3
6.Is(are)the weD(s) Permanent or Tempos Signature ofCertifi Well Contractor ; Date
() ary r
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: litccs or ()No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 IVell 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 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 TOTALNUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: 2 0 p 0 (ft) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths if different(example-3Qa 200'and 2Qa l00' construction to the following-
10.Static water level below top of casing: I'J (ft-) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service I
/ Center,Raleigh,NC 27699-1617
11.Borehole diameter: to l/r, (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: �oTi9fi above,also submit one copy of this form within 30 days of completion of well
construction to the following: G
(i.e.auger,rotary,cable,direct push,etc.)
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Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ,3 Method of test: &AAn 24c.For Water Supply&Injection Wells: In addition to sending the form to
1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: PT Amount: / 3 C)2_ completion of well construction to the county health department of the county
where constructed i
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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