GW1--00020_Well Construction - GW1_20231218

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.We ontractor Information:
( 'C/ �( r;1 14.WATER ZONES ! ;I
Well Contractor Name FROM TO DESCRIPTION
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased Wells)OR LINER(if ap likable)
Water Wizards Inc FROM TO � DIAMETER
TE j I S�� MATERIAL
ft ft in v
Company Name 16.INNER CAS G OR TUBING(geothermal closed-loop) t�
2.Well Construction Permit ft: TO DIAMETER ' THICKNESS MATERIAL
List all applicable well construction permits(Le.U1C,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft ft. 1 in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
111 Agricultural DMunicipal/Public ft ft. in.
111 Geothermal(Heating/Cooling Supply) .residential Water Supply(single) ft It. in.
*Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
I Irrigation FROM TO MATERIAL EMPLACEMENT OD&AMOUNT
Non-Water Supply Well: 0 ft. 90 ft ?e-4(3 �f p©( 5/t�7
a Monitoring I, 'ecovery ft. ft ('�' `N 4�Y1
Injection Well:
ft. ft. '
I Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM ,TO MATERIAL EMPLACEMENT METHOD
IN Aquifer Test DStormwater Drainage ft ft
al Experimental Technology DSubsidence Control ft. ft. ,
11 Geothermal(Closed Loop) OTracer -20.DRILLING LOG(attach additional sheets if necessary) -
FROM TO DESCRIPTION(color,hardness,soilrack type,grain size,etc.)
)r Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) ft ft
II
4.Date Well(s)Completed:jiaajWell ID#113/24 ft. ft. -• s. ; t
5a.Well Location: ft ft. s 't."�.'„�'�•...•is as L-,..
Admiral Properties LLC f<. ft PSI 1 S 9n2/
Facility/Owner Name Facility 1D#(if applicable) ft. ft. '
ft. ft. tn;.:rr,�2.�._^n:'•-• :r .;::; i l'::,
2202 Burlington Rd Roxboro NC 27573 �., ,.,-1,?
Physical Address,City,and Zip H ft ,,
Person 21.REMARKS , /
County Parcel Identification No.(PIN) SiN/5 i i t :''W.. /J, k"/�-11 .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: c��ell
(if well field,one lat/longis sufficient)
+ 22.Certification:
�,oa i '��-7� � �! `75 7 ,`W , / �znv it /3/of f
6.Is(are)the well(s) eminent or OTemporary Signature of Certified Well Contractor Date
� By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
fa
7-Is this a repair to an existing well: •et or ONo 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 ofthe 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: iSUBMITTAL INSTRUCTIONS ff
9.Total well depth below land surface: 1 74" (ft.) 24a.For All Wells: Submit this'form within 30 days of dim_pletion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following: I •
10.Static water level below top of casing:/ (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing;use"+" ,.. 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 (41 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 246)\ _
above,also submit onelcopy of this form within 30 days of completion of well '
12.Well construction method: 4 construction to the following:
(ie.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: f V��`,,,,,, �LL,��, ///Ill
�T+`-f' 24c.For 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: J' I-� Amount: &0l/l7'� completion of well construction ti 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