GW1--06912_Well Construction - GW1_20231030

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only: i
1.Well Contractor Information: i '
Blake Sanford 14.WATER ZONES F .
Well Contractor Name FROM TO DESCRIPTION
NC Well Contractor Certification Number `� ft.
15.OUTER CASING(for multi-ca ells)OR LINER(if ap lIcable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
O
Company Name 0 ft- /6 it LI I 1n. S'0r90-6 41 VG
16.INNER CASING OR TUBING(geothermal dos•.-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(le.UIG County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. 1°
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Publc ft. ft. In.;
Geothermal(Heating/Cooling Supply) Q'residential Water Supply(single) ft. ft. In.
industrial/Commercial DResidential Water Supply(shared)
111.GROUT
i Irrigation FROM TO
TO MATERIAL EMPLACEMENTS O�D7&_AMOUNT
V
Non-Water Supply Well: f. 76 n' POC -1714411 p�,�f"Qj� o��Jt�1
Monitoring IS • •overy ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Bather FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test f Stormwater Drainage ft ft.
Experimental Technology OSubsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)°
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) flOther(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed:/✓I/Well ID#77/27 ft. ft. Y i
5a.Well Location: ft. ft.
Lonnie Rogers ft ft. O C T 3 0 2023
Facility/Owner Name Facility i W(if applicable) ft InfrI:r^.. in^ :ir,. ' ul•
O.,:
1166 Halifax Rd Roxboro NC 27573 ft. ft. j DW ,2 r.
ft. fa
Physical Address,City,and Zip
Person 21.REMARKS . - .
County Parcel Identification No.(PIN) 4. 1 L✓fir `�-/" e 1
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - Ci4 S(r(PI3)
(if well field,one lat/long is sufficient) 22.Certification: J
6.Is(are)the wells) " ermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cent*that the well(s)rrns(were)constructed in accordance
7.Is this a repair to an existing well: Cifees or ONo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well 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 GeoprobefDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to'provide additional well site derails or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: j SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Ot>4 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd(erent(example-3@200'and 2@100') construction to the following: 1
10.Static water level below top of casing: , . (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: (0 '1 (in.) 24b.For Injection Wells: In additio i to sending the form to the address in 24a
1/J _,l—i above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: IC�''t�'_( construction to the following:
(ie.auger,rotary,cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I •
13a.Yield(gpm) Method of test: J 24c.For Water Supply&Infection Wells: In addition to sending the form to
��L �^ J, the address(es) above, also submit ore copy of this form within 30 days of
13b.Disinfection type: WA- Amount: �l1-"' 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