GW1--00022_Well Construction - GW1_20231218

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: ,..
1.Well Contractor Information:
G(•',C, CM 0 IL 14.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION..
y 147
y - - 7 I4i ft 't I P'h�
ft. . ft. 1
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Wizards Inc FROM TO DIAMETER' THICKNESS MATERIAL
'i Co Name 0 ff. / 3 ft. & i/i.1 i is s u Q "'l' I P V L
Company �+,p, p e� r� 16.INNER CASING OR TUBING(geothermal closed-loop)loC
2.Well Construction Permit#:OSWP-001082-2022
V -oo Ov�-LOZG FROM TO DIAMETER' THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State,Variance,etc) ft. ft. in.
-ix
ft. ft. !in
3.Well Use(check well use):
SCREEN17.
Water Supply Well: FROM TO DIAMETER ,SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public R. ft. to '
Geothermal(Heating/Cooling Supply) fesidential Water.Supply(single) ft. ft in.
Industrial/Commercial EiResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO ' MATERIAL• EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft (O 3 ft !i f i iy143 Poe. ,A -I- 14V T1e
Monitoring Recovery ft ft. .1 n nl0.4e cQ Sb I bs�- •
Injection Well: ft • ft. t
Aquifer Recharge DGrou ndwater Remediation •
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery QSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IDStormwater Drainage ft R
Experimental Technology OSubsidence Control ft ft. t
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Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(tutor hardness sunhat*type,grain size,eec)
0 ft LI ft ove-rI4t.r.JG'1 .
4.Date Well(s)Completed:I I- I-a 3 Well l)#A71 251 y ft a t,1 ft ( J CtQ
5a.Well Location: ALI ft W C O ft. &QV., ��
Anna Santiago ft ft. 47
Facility/Owner Name Facility ID#(if applicable) ft ft ',•'`k ,y.Y, _T r 't/T Li
2788 Old Allensville Rd Roxboro NC 27574 ft ft. Z1L3
Physical Address,City,and Zip ft. R CC
Person 21.REMARKS , _ , •Tc- :3 vf1 t
County Parcel Identification No.(PIN) [NV 0..
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3eP.17/(3L13f1 N -71d.9.Raa397 w �i-a-o23
6.Is(are)the well(s) ernlanent or DTemporary rtpratrueofCertified Contractor 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: I Yes or lio with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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 TOTAL NUMBER of wells construction details.You may also attach additional pages if necessary. .
drilled: I'
SUBMITTAL INSTRUCTIONS ,
9.Total well depth below land surface: 5'OO (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ildierent(example-3Qa 200'and 2@100') construction to the following: '
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10.Static water level below top of riming: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing use"+"t1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: vs' (m.) 24b.For Injection Wells: In additi I to sending the form to the address in 24a
P. 11 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: A;r 1 O"ktr y construction to the following:
(ie.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: r�_ 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I 1 ;A 4 Method of test ll id wA rap fr: 24c,For Water Supply&Injection Wells: In addition to sending the form y to
�+ 7 the address(es) above, also submit i one copy of this form within 30 days of
13b.Disinfection type: 14I 1-1 Amount: a 3 t� 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