GW1--06910_Well Construction - GW1_20231030

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WELL-CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
.f)("1,et 01414 1 14.WATER ZONES '
Well Contractor Name FROM TO DESCRIPTION -
c D ft. 1 1 ft.
I 1
36 VI- � ,I ft.
NC Well Contractor Certification Number !/ D
• ROUTER CASING(for multi-cased Swells)OR LINER(if ap licable)
Water Wizards'Inc FROM TO- DIAMETER THICKNESS MATERIAL
Company Name O f. 8IO fL; I i is Cr0g._26 Pi//�
q® 16.INNER CASING OR TUBING(geothermal)closed-loop)
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2.Well Construction Permit#: t5IA)1—000 7 P -2 FROM TO DIAMETER• THICKNESS MATERIAL
List all applicable well construction permits(La UIC,County,State Variance.etc.) t4 ft. in.
3.Well Use(check well use): ft. it: in.
Water Supply Well: 17.SCREEN
� FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agricultural '':, Yam•`*� ipalPublic ft, ft. in.,
Geothermal(Heating/Cooling Supply) nkcsidential Water Supply(single) ft. ft. is
IndustrialICommereial OResidential Water Supply(shared) IS.GROUT
i Irrigation FROM . TO MATERIAL EMPLACEMENT OD&AMOUNT
Non-Water Supply Well: 3
coon ing f�Recovery D •{t_I ce.4.,t �i,�r s�f�l .c
Injection Well: go
� yy
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable) -
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [jStormwater Drainage ft. ft.
{ Experimental Technology I0Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer -20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DFSCRIPI ION tor, ass sosiroek type Qraaia etc)
) ft 7 ft- O1 H rb;,-eit•-‘ -
4.Date Well(s)Completed:/&—S 2- ,Well ID#115/58 7 fI 3,g ft. 30,2..114
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5a.Well Location: 3S ft- 2-tie, ec-ir-1,'
Y'®Lk -eG.--Sa . - (')r
Ashraf Kamel ft. ft. •
Facility/Owner Name Facility lD#(if applicable) ft. . ft. '
548 Robert Norris Rd Roxboro NC 27574 ft. ft. y' -,{ ' .,. • f`
Physical Address,City,and Zip ft' ft Person 21.REIVIARKS l,nn
C 13 ill 2023 .
County Parcel Identification No.(PIN) • - -
Ifl.3r Nr",:z. .7g4-2 l?Gta
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: f�`":`:C "='1
(if well field,one lat/long is sufficient) 22.Certification: ' 11
3fe)-39 q os N 71• OJc339 w Y
6.Is(are)the well(s) rmanent or Temporary Igoe of Certifie We Contracto i Date
�� By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
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7.Is this a repair to an existing well: Ii Yes or 1 with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a:-
lfthis is a repair ftll 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: 't; .18.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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2-'7, t/ O 24a. For All Wells: Submit this farm within 30 days of completion of well ,
For multiple wells list all depths ifdifferent(example-3@200'and 2(a 100) construction to the following: -- '
10.Static water level below top of casing: .2 (ft-) Division of Water Resources,Information Processing Unit, -
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: (in) 24b.For Infection Wells: In addition to sending the form to the address in 24a 12.Well construction method: ilRol-c-i''l -
above,also submit one copy of this form within 30 days of completion of well
construction to the following: ; .
(Le.auger,rotary,cable,direct push,etc.) -
Division of Water Resources,Underground Injection Control Program, ' • '
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test Qtw)t".2._ ,044gor Water Supply&Injection Wells: In addition to sending the form to ,
the address(es) above, also submit one copy of this form within 30 days'of •
13b.Disinfection type: ." ! 7 Amount //ot.tarl,e g completion of well construction to the county health department of the county •
where constructed. -
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources -Revised 2-22-2016' •
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