GW1--06901_Well Construction - GW1_20231030

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: - -
1.Well Contractor Information:
6(,,,,i,, 'd. t
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
44 9 �5-C lifs'ft. s© f` 1cT v1/1
ft. ft.
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
Company Name 0 f. ft. t/ I in 6 /`/�c'
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(e.UIC,County,State,Variance,etc.) ft. ft. ' in.
3.Well Use(check well use): ft. is
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft In.I
Geothermal(Heating/Cooling Supply) gtt6idential Water Supply(single) n. ft. In,
Industrial/Commercial E3Residential Water Supply(shared)
18.GROUT
I Irrigation FRONA TO MATERIAL EMPLACEMENT OD&AMOUNT
Non-Water Supply Well: it
G 3 ft. f J l.ci47 Pe re-A ( J)Ij5
Monitoring ', r very ft. ft /` r
Injection Well:
ft. ft.
Aquifer Recharge II Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft ft
Experimental Technology E3Subsidence Control ft. ft.
Geothermal(Closed Loop) OTiacer 20.DRILLING LOG(attach additional sheets if necessary) -
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DFSCRLPI lox(color,badness suillroek type araia efu etc.)
ft. ft.
4.Date Well(s)Completed:a/14/9_3 Well ID#113 7 1 ft. ft. `._,
5a.Well Location: f. ft. f - : ,,,,r C.,' "y, ,�,)
Diane Loental ft f. 1 0 C T 3 02023
Facility/Owner Name Facility ID#(if applicable) ft [L
2215 Blalock Dairy Rd Roxboro NC 27574 ft ft. In O,-..f '� 'r -: ��!rig fir,,;{
Physical Address,City,and Zip
ft. ft I. esv s,:; Lrl:
Person 21.REMARKS � .`��/ --
County Parcel Identification No.(PIN) ��t.'�J( 7-1 l r ` C /- -.r .a.. 4
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: `' -1"
(if well field,one lat/long is sufficient) 22.Certification:
3<a. 36 6.9c5 ci --7 ,() 9)3074 w `?- �•Nec'e e- lO/t -/23
6.Is(are)the well(s)�rmanent or Temporary Signature of Certified Well Contractor Date
�/ By signing this form,I hereby certify that The sell(s)was(were)constructed in accordance
�
7.Is this a repair to an existing well: i or QNo with 15A NCAC 02C.0100 or 15A 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 thewell 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 rW-1 is needed. Indicate TOTAL NUMBER of wells construction details.You may also attach additional pages if ne,-,•csary.
drilled: SUBMITTAL INSTRUCTIONS
depth below land surface: / `�1
] /J
9.Total well ft
( ) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi#"erent(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: Q (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: (.G4--1 (in) 24b.For Infection Wells: In addition to sending the form to the address in 24a
�yt/ above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: O" y construction to the following:
(ie.auger,rotary,cable,direct push,etc.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPL�Y{ WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) G V Method of test: f V1/ f 24c.For Water Supply&Infection Wells:ells: In addition to sending the form to
/r the address(es) above, also submit one;copy of this form within 30 days of
13b.Disinfection type: I-I 1 I+ Amount: (/J4T1"--f- 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 j Revised 2-22-2016