GW1--06946_Well Construction - GW1_20231027

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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14.WATER ZONES• I!
Well�Con/tractor Name FROM TO DESCRIPTION
vlC4‘ - C "(6n' 9a2-n' tg��h^.
ft. f. i
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 v / 1 Lf i 6QI,./. fivc_.
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.
3.Well Use(check well use): ft' ft 1°
Water Supply Well: 17.SCREEN
FROM TO DIAMETER. SLOT SIZE THICKNESS MATERIAL
Agricultural OMunic I/Public ft, ft. in.
Geothermal(Heating/Cooling Supply) idential Water Supply(single) it ft in.
Industrial/Commercial OResidential Water Supply(shared)
18.GROUT
I Irrigation FROM TO MATERRIAAL` ' EMPLACEMENT METHOD&-AMOUNT
Non-Water Supply Well: () ft- 5'/r ft p d-La4 J,,rnt� 1 oaG�//.l -
I Monitoring ecovery ft. ft. ,. e
Injection Well:
ft. ft.
AquiferRecharge QGmundwater Remediation 19.SAND/GRAVEL PACK(if applic6ble)
Aquifer Storage and Recovery O4alinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft ft. '
Experimental Technology DSubsidence Control ft. It.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(coma hnrdaess Baa/xnt,Ct4p4 warn size eta)
/ ft ft _
4.Date Well(s)Completed: IO/I(a Well ID# ft. ft s ,� ,'C., `'�r r rT 3
5a.Well Location: fr ft. OCTrf �O,p�
State Of North Carolina ft. ft 1 1 1 L
Facility/Owner Name Facility Mt((if applicable) D. ft. lnfor : )7n P57,::�.;.il!F,R Ut X
5662 Cornwall Rd Oxford NC 27565 ft ft
( 'vC1L0
Physical Address,City,and Zip ft ft.
Granville 21.REMARKS /��`
County Parcel Identification No.(PIN) �lT1 l'he.- /-Q-0-cc"�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: C am' in
(if well field,one lat/long is sufficient) 22.Certification:
56°1'4 '3 i 7 c W637`KCo4/z " W 1v,i, /,/i•o -3
6.Is(are)the well(s) ermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cenify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: es or OPT° with 15A NCAC 02C.0100 or I5A 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 OW-1 is needed. Indicate TOTALNUMBER of wells construction details.You may also attach additional pages if nw•Pcsary.
drilled: I i
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ( ) 24a. For All Wells: Submit this1 form within 30 days of completion of well
For multiple wells list all depths ifdiiUerent(example-3 00'and 2 l00') construction to the following:
10.Static water level below top of casing: a (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: &1:4W (in.) 24b.For IniectioR Wells: In addition to sending the form to the address in 24a
� st/ above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1Y' II construction to the following:
(i.e.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) I �1 Method of test: 24c.For Water Supply&Injection n Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
1
13b.Disinfection type: �'1 /4 Amount: ' ti.-c.i 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