GW1--00026_Well Construction - GW1_20231218

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
I I
Eric Cook 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
4577A 176. ' I O n 10 PiH
, ft: ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name O ft. log? ft. 6rq sDRaI Pvc.
�+ 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:OSWP-000927-2022 ,FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft ft. ' In.
3.Well Use(check well use): ft. ft.
Water Supply Well: 17.SCREEN I..',
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft ft. In.
Geothermal(Aeating/Cooling Supply) Residential Water Supply(single) ft. ft in.i
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT - . . '
Irrigation FROM TO �MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it
(p 3 n' ' '' Itlectu3 PcxAr1) +ti dct4e re)
Monitoring- QRecovery ft. ft. i place 7S•v 1 js
Injection Well:
ft. ft
Aquifer Recharge Groundwater Remediation
•.19:SAND/GRAVEL PACK(if applicable) -
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft' ft
Experimental Technology DSubsidence control ft ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)FR
Geothermal(Heating/Cooling Return) [ill Other(explain under#21 Remarks)
oM TO DESCRIPTION(color,hardness,solUmck type,grain size,etc.)
r� b fL 3 ft- Li
4.Date Well(s)Completed: I I.-c "a 3 Well ID#86/53 3 ft. y� ft. Kid C IOI
5a.Well Location: Lig.f ?cV ft- true., 120r-�
Katina Hayes ft. ft. - E' ''1 i''t„;--
r V 4 >
Facility/Owner Name Facility ID#(if applicable) ft. ft. "' 1
1734 Allensville Rd Roxboro NC 27574 ft. ft. 17F.t 1 8 2021
Physical Address,City,and Zip ft. ft. into:rrr:,-,,:,-,, ,-.),,^-
Person 21.REMARKS 4 r}t, .,:.:.-,.•,•,::.ny UR:
County Parcel Identification No.(PIN) .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 22.Certification:
36. 3101 ' N ,74'.is- 3) w 1,4--
Lis-77)/ 11-3 a3
6.Is(are)the wells) Permanent or DI Temporary
Signature of Certified Contractor ; Date
By signing this form,I hereby certify that the wells)was(were)dinstructed in accordance
7.Is this a repair to an existing well: DYes or Et< with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
((this is a repair,fill out known well construction information and erp/ain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis form.
23.Site diagram or additional well details:
8.For GeoprobelDPT 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. M Indicate TOTALNUBER of wells construction details.You may also attach additionalpages if necessary.
drilled: 1
M
`,�, SUBTPPAL INSTRUCTIONS
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dt(ferent(example-3@200'and 2 100') construction to the following: j
me
10.Static water level below top of casing: c S 00 Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" t� 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: CD /O (hi.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
• 12:Well construction method: A:r aQ-11-0.r i construction to the following: 1
(i.e.auger,rotary,cable,direct push,eta.)
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 Method of test:1 )otw7dl O"�1iU 24c.For Water Supply&Injection,Wells: In addition to sending the form to
ff oo p� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 14i1"! Amount o z. completion of well construction to ide 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