GW1--04408_Well Construction - GW1_20240723

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Blake Sanford 14.WATER ZONES
Well Contractor Name FROM TO D RirnoN _
4458-C : '�. ; X ft. a 2 fvt
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Wizards Inc FROM TO DIAMETER
DIAMETER THICKNESS I MATERIAL0 ft. (jl t.) ft in. (}.. . Le Vc.,
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM r0 DIAMETFR UHICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,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 0Municipal/Public ft. ft. in.
DGeothermal(Heating/Cooling Supply) X)Residential Water Supply(single) ft. ft. in.
f Industrial/Commercial D Residential Water Supply(shared) 18.GROUT
Il Irrigation FROM TO MATERIAL 1 EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: (J e. 1 (C,) ft i'1�2i.3'�t' &LI/. S Q (/)S
QMonitoring DRecovery ft. ft
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD _
Aquifer Test �Stonnwater Drainage h. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) QTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM ft TO
ft. DESCRIP'rl(Y\(color,hating toil/rock type,pain size etc.)
4.Date Well(s)Completed: ?/21/�3 Well ID# '79/237 ft. ft. - F �� •' 't r s-
1 i.... c: 1 -I. •
ft. ft.
5a.Well Location: _
Kathy Bradsher ft- ft. -_ JUL 2 c [024
Facility/Owner Name Facility 1D#(if applicable) ft. ft 3, t
969 Gabriel Jones Rd Roxboro NC 27574 ft. ft. - Irdor rx.r�.i ; C.: r.i"
Physical Address.City,and Zip ft. ft.
Person A `C1 - '1 3r1
21.REMARKS
County Parcel Identification No.(PIN) -4',"-�S"+/►`( f7(ir C /` N�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: C.05(" •l j JJJ
(if well field,one lat/long is sufficient)
f� 22.Certification:
q/e-/,'. c---64c6, .....-
6.ls(are)the well(s)iX Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or JJNo 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 of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this farm.
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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: /�rT SUBMITTAL INSTRUCTIONS
2
9.Total well depth below land surface: SO (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3C�00'and 2@ 100') construction to the following:
10.Static water level below top of casing: 4 (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: (I,(--( (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
,r� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: I JJ
sr ` construction to the following:
(i.e.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: 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: /4 11" Amount: Lug . completion of well construction to the 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