GW1--00046_Well Construction - GW1_20231218

kirif Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.W Contractor Information: I
[g -#4-c- S cd 14.WATER ZONES i
Well Contractor Name FROM TO DESCRIPTION
Li(c<�C 7 � c � ft. 6 o 6 m
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(If ap llcable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 76 fL 44 1- Sg L �
tQ
16.INNER CASING OR TUBING(geothermal dosed-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. , in
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) gt dential Water Supply(single) t ft. in.'
Industrial/Commercial DIResidential Water Supply(shared) 15.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Om -26.t Prr ficr"e 4/ ) f r
Monitoring ip. •: every ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage t D'
Experimental Technology DSubsidenc,e Control ft. ft.
Geothermal(Closed Loop) EnTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ]Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sotOroek type,gain size,etc.)
ft. ft.
4.Date Well(s)Completed:jvnvvg3 Well ID# ft. ft.
5a.Well Location: ft. ft. ", •
,�
Dorothy Walker t t '"-41.i
Facility/Owner Name Facility ID#(if applicable) ft. ft. ..3
6508 Huntsboro Rd Oxford NC 27565 t t
04
Physical Address,City,and Zip
ft. ft. n. LI-
Granville 21.REMARKS `
County Parcel Identification No.(PIN) h54 1/(2A Ilk trits3( '12.e
5b.Latitude and longitude in degreesfminutes/seconds or decimal degrees: -'6"'�� ft:, ,
g(ifwell field,one tat/long is sufficient) - � 22.Certification:ication:
6-0 w 1Q-1,,,_
6.Is(are)the wells) ent or Qi Temporary Signature of Certified Well
Croat`'tractor 17
ate
Dili By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dil or E3No with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out lmown 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 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7 (R) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 00'and 2@100) construction to the following: I'
10.Static water level below top of casing: (ft.) Division of Water ResoI roes,Information Processing Unit,
If water level is above casing use"+"/• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ACC l i (in.) 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: �-0:174 -s r construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) b 0 Method of test: 24c.For Water Sanely&Iniecti'on 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: > -I' A- Amount: completion of well construction i the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource's Revised 2-22-2016