GW1--04431_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 DESCRIPTION
4458-C fit. .�(iUn L ?1'V1
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a licable
Water Wizards FROM TO DIAMETER THICKNESS MATERIAL.
0 f6 U ft. i in. A. 6/0o 6:
Company Name
16.INNER CASING OR TUBING(geothermal dosed400p)
2.Well Construction Permit#: 300 I. 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): R. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural DMunicipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft' ft. in,
[jindustriaUConunercial QResidential Water Supply(shared) iS.GROUT
+lirrlgation FROM TO MATERIAL EMPLACEMENT THOD&AMOUNT
Non-Water Supply Well: 6,)ft. ?(.) ft. 1 _Liss, po r�- atvk1 D_
Monitoring Recovery ft. J fL fV d v " / �?
Injection Well:
ft. ft.
J Aquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStonnwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM
ft. TO
ft.
Dt'_SCRIP DESCRIPTION(cube,hardness,soil/rock type,grain size,etc)
Geothermal(Heating/Cooling RReturn) Other(explain under#21 Remarks)
4.Date Well(s)Completed: Well ID# it. ft.
ft. f
5a.Well Location: ft. ,'• ;^
k.'1... t/ L.'L-r
Shady Grove Methodist Church ft. ft.
Facility/Owner Name Facility 1D#(if applicable) it' ft. JUL _
1781 Shady Grove Rd Providence NC It' ft.
Physical Address.City,and Zip ft. ft. [7J•it allOG
Caswell 21.REMARKS y,
County Parcel Identification No.(PiN) . 1 I t1e4 I �'"/ .-� �1
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �i,Yikt J
JJ1
(if well field,one tat/long is sufficient) 22.Certification:
(; K/'116% N •" 2`I. // 1(x) w 612,/ -- �� �1%2,c1
6.Is(are)the well(s)UJPermanent or DTemporary Signature of Certified Well Contractor Dale
By signing this form,/hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or [NO with I sA 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 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 I GW-I 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: ✓� (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii different(example- !JC 00'and 2@100) construction to the following:
10.Static water level below top of casing: t (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.use"+"9 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: l� Lti (in.) 24b.For Injection Wells: hi addition to sending the form to the address in 24a
t 7 above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: I 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) L Method of test: �1 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: 14 .lL 4 Amount: '1"" 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