GW1--01449_Well Construction - GW1_20240301

Print Form J
• - I _- ,.
WELL CONSTRUCTION RECORD(GW-1) ,$,-- For Internal Use Only: .
1.Well Contractor Information:
' So*J Of=T6 M
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
30,244 g 3 aOL 3Sft 2 Gi,A 'e.
ft. ft.
NC Well Contractor Certification-Number 15.OUTER CASING(for multi-cased wells)OR LINER(If ap Ucable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name O tt 1 2O ft• W'�,iu . /�� /cps ,,
OS W I 008341 d023 16.R INNER CASING OR TUBINGDIAMETER
(geothermal cl THICKNESS
MATERIAL
Well Construction Permit#. � '� FROM TO DIAMlTER MATERIAL
List all applicable well construction permits(i.e.UIC,County,State;Variance,etc.) ft. ft. 'In.
ft3.Well Use(check well use): - In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER ,SLOT SIZE THICKNESS MATERIAL
DAgricultutal DM cipa1/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) roWesidential Water Supply(single) f, it. in,
IJlndustria1/Commercial DResidential Water Supply(shared) 18.GROUT- - - - -
f irrigation FROM TO ``MAATERIAAL EMPLACEMENT METHOD&AMOUNT.
Non-Water Supply Well: 0 ft 1 AO ft "
t N�Ok PwAfw I Pe1sRe0 17061b
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery
-
Aquifer Test
Salinity Barrier FROM TO MATERIAL ary)EMPLACEMENT METHOD
IJStommwater Drainage ft. ft.
Experimental Technology (Subsidence Control ft is
Geothermal(Closed Loop) OTraoer 20.DRILLING LOG(attach additional sheets if necess
OGeothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardaes soil/rock type Rrata sbr etc.)
A�/ 0ft. 7 QVB A 8 r&DE N
4.Date Well(s)Completed: a-7-2`7 Well ID#A47/262 ft., He ft. p3.eN,P
5a.Well Location: I ) ft 346 riWl4/ci& /LOtrk
Caruso Homes r` ft. ; _
Facility/Owner Name Facility IDS(if applicable) ft' ft- P f"ti• ''' 1?-_-:-_ \ 1`
E D
•
4320 Chub Lake Rd Roxboro NC 27574 fr. ft. :;
ft. ft. hilAIf 1) 120/4
Physical Address,City,and Zipi
Person 21.REMARKS -
tntofmazrFil 7:{; g Unit
County Parcel Identification No.(PIN) I O/ZO.0
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well held,one lot/long is sufficient) 22.C, i tc. ,on•
36,NN�1 t Ny8 N •11% ggot (ps{?9 w / Z' 7 '2.9
6.Is(are)the wei(s)irmanent or Temporary '•'of Certified Well Con&,,,iii-
lipsl Date •
By si y 'ng this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or �Io with 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the null owner.
repair under 021 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 TOTALNUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 7�J
O (ft-) 24a. For All Wells: Submit this;form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 25" (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing use"+"' 1617 Mail 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: R above,also submit one copy of this form within 30 days of completion of well
ig�y 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
B 13a.Yield(gpm) 3 Method of test: LO w N 24c.For Water Supply&Infection 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: H Amount: II, 2 0 . completion of well construction tot 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