GW1--04409_Well Construction - GW1_20240723

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
Blake Sanford 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name o i-
' # ) > > Q fJJn
4458-C JJ ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased weI OR LINER(if applicable)
Water Wizards Inc FROM TO DIAMETER THICKNESS MATERIAL
ft. 4��, ft. / in. ,(� Pf✓G�
Company Name —1
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM 1'o DIAMETER I HIC KNESS NIA IERIAI.
List all applicable well construction permits(i.e.UiC County.State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft ft. la.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE: THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft ft. in.
Industrial/Commercial DResidential Water Supply(shared) IS.GROUT
Irrigation FROM TO MATERIAL_ EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: r' ft. t-,!J fftj, ,': -1-- /I,_ , "'!!•• / f h Q//13
Monitoring Recovery A. ftJ
Injection Well:
ft. ft.
Aquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL PACK(if applicab)
Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft, ft.
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIP110N(color.hardness.soil/rock type,grain sire,etc.)
Geothermal(Heating/Cooling Retuurnn)7,1(� Other(explain under#21 Remarks) ft, ft.
4.Date Well(s)Completed: /`v J�etf[ON ss 73 ft. ' ft.
ft. fa . -...,.‘. - .' sy . .S.,.,.
5a.Well Location:
DDS Inc ft.
f` _ JUL 2
Facility Owner Name Facility ID#(it-applicable) ft. ft.
521 Clay Thomas Rd Roxboro NC 27574 ft. ft. lilt::%+eA't i. r' "_ . ; ., ,
Physical Address,City,and Zip
ft. ft BMC. '�J
Person L4/_— "l�j 21. MARKS p (y�
County Parcel Identification No.(PiN) r t 1, r `-� i �� 1'a'�� '1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (;e a - f J
(if well field,
field,one la�blloongg is sufficient) —� �,��,/ 22.Certification: t�
—I • ' / . t,"1 � N—/`jf. -I_/�a a li�60 w if/7,/ r�IC�"' 1 C/3 1/0�(1
6.Is(are)the well(s) Permanent or DTemporary 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: LI a s or DNo 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 hack 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: IOC) (ft.) 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 1(a100) construction to the following:
10.Static water level below top of casing: 2.- (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: V `1-1 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
1^ �Q above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: °�" / construction to the following:
(Le.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
LI13a.Yield(gpm) Method of test: D(/(- f 24c.For Water Supply& Injection Wells: in addition to sending the form to
/ i L `0 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1,4 r 14 Amount: . -�> completion of well construction to the county health department of the county
where constructed.
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016