GW1--00061_Well Construction - GW1_20231218

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.W Contractor Information: ;
r '
cry\Vt�i 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name I3
Plil
NC Well Contractor Certification Number -
15.OUTER CASING(for multi-cased wells OR LINER(if ap licable)
Water Wizards Inc FROM TO/' 'TOO DIAMETE THICKNESS MATERIAL
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Company Name `� ` � PvC
11JJ (� 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: 3a i t 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' 1D
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
X Agricultural OMunicipal/Public R. ft. in. ,
*Geothermal(Heating/Cooling Supply) BRgriential Water Supply(single) ft. ft. in.
X Industrial/Commercial [Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT OD&AMOUNT
Non-Water Supply Well: 0 >t 7r-e, ft. 9
/gQL1 00(�¢e: a J�S-
jn Monitoring ',-overy ft. ft. +' . /
Injection Well: -
R Aquifer Recharge DGmundwater Remediation f ,
19.SAND/GRAVEL PACK(if applicable)
jjllAquifbr Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
I Aquifer Test (jStormwater Drainage ft. ft. j
®Experimental Technology OSubsidence Control ft. ft.
211 Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional'sheets if necessary)
11 Geothermal(Heating/Cooling Return) [:Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hwlnms son/rock type grain sizes etc-)
i ` / ft. ft. l' _
4.Date Well(s)Completed: /I/ 3 J� Well LD# ft' .--'-
5a Well Location: ft. fL I w r ' r--•. .?
l I Van D Allen ff. rt. • ' L b Z023
Facility/Owner Name Facility ID#(if applicable) ft. ft I'fl a%ram t:_;l ;-r..
1531 Old Satterfield Rd Blanch NC 27212 ft. fL O` ,..-,,.)0i ts* ;'
Physical Address,City,and Zip f4 R.
Caswell 21.REMARKS
County Parcel Identification No.(PIN) r /)`4 , I t i rt ` e r t a'n"'/
^'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: tA3
(if well field,one latflong is sufficient) 22.Certification: •
( ar ,efI 3 N 7a°Il'r,- fd7 a'-1'f/1W
Signature Ovir4‘fo,.(4 I 1/4636A3-3
of Certified Well Contractor �. Date
•6.Is(are)the well(s) nennt or Temporaryi,
� By signing this form,1 hereby ceit that*well(s)was(were)constructed in accordance
It•rs
7.Is this a repair to an existing well: or No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repay,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 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: J O�� (f) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2®100) construction to the following:
I.
10.Static water level below top of casing: 0 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"k" 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: h�PJ �1
to_U _ ��l above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLLLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Iniection Wells: In addition to sending the form to
l ,,�C the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 14 7 I Amount: OZA' ✓ completion of well construction to tfie'county health department of the county
where constructed. `
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016