GW1--05873_Well Construction - GW1_20230912

Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1. IIContractor Information:
SO-Vk(-01,
14.WATER ZONES I
Well Contractor Name
/ FROM TO DESCRIPTION/
ft- co2
�K'r—6 I ft. 1 3o ft. �pin
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL MATERIAL
Q ft. 6/ ft. _1 in. 5012C96 re
CompanyName 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.UIC,County,State,Variance,etc.) ft. ft. in.
ft3.Well Use(check well use): in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water,Supply(shared) 18.GROUT
, Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' Q ft. pOC pQ ore 2t446<
Monitoring PA •:overy ft. fL 1
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Reinediation '
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and.Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft. i'
Experimental Technology Elsubsidence Control ft. ft I'
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary) ,
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness sollhoc&type grain size,etc)
(
ft. ft.
4.Date Well(s)Completed: rfi I A Well ID#MO/9 ft. ft
5a.Well Location: ft ft jY r
Harold Ray Moore ft ft
Facility/Owner Name Facility ID#(if applicable)
ft. ft. SEP 1 2 2023
2361 Gentry Ridge Rd Roxboro NC 27574 ft. ft (rtf :rfacien Pm = (Sri
Physical Address,City,and Zip ft. ft. I CAN tR;SOG
Person 21.REMARKS /� - I;
County Parcel Identification No.(PIN) _Ibo 43—J/�'r °L�- (�°�� -For [ ` `df
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
c,9-5 el ri 1
(i well field,one lat/long is sufficient) 22.Ce Cation
Gila-76i7o N •—`7g40 ,7/cr W if a Ski
6.Is(are)the well(s)RI ''rmanent or OTemporary
Signature of Certified Well Contractor i 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: G I� s or EiNo with ISA NCAC 02C.0100 or ISA 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 tire well owner.
repair under 421 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 1W-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS j
9.Total well depth below land surface: i 30 (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@l00) construction to the following: I
10.Static water level below top of casing: (ft-) Division of Water Resoure es,Information Processing Unit,
Ifwater level is above casing,use +'•+" 1617 Mall Service Center,Raleigh,NC 27699-1617
6I1.Borehole diameter: '. ( (in) 24b.For Injection Wells: In addition to sending the form to the address in 24a
,�M��Q above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: tp'•C/v u a e construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS
ELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699=1636
PL/
13a.Yield(gpm) (J�ti Method of test: J�� 24e.For Water Supply&Injection Wells: In addition to sending the form to
i 1 /1 ( �,J J/.� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: l'1 4 !. Amount: a—/o fA1)i,A003 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 I Revised 2-22-2016