GW1-2022-09066_Well Construction - GW1_20220923

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Contractor Information:
David Hardy 14.WATER ZONES
Well Contractor Name
FROM TO DESCRIPTION
ft. fL
2906-A
NC Well Contractor Certification Number -
15.OUTER CASING for ulti-cased wells)OR LINER(if ariplicable)
Aqua Drill, Inc. XROM TO DIAKETER THICKNESS I M&Rw
Company NameICINNER CASING OR TUBING(giothermaTefoseil-loop)
2.Well Constru,.ction Permit'#: -17 1 FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,Couno-,State.Variance,etc.) ft. ft. in.
3.Well Use(cheek well use): ft. fL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:JAgricultural OMtraicipal/Public % ft. in.
lGeothermal(Heating(Cooling Supply) pResidential Water Supply(single) ft. ft.
3Industrial/Commercial OResidential Water Supply(shared) —
111.GROUT
lirrigation FROM TO ATE EM CEMENT METHOD&AMOUNT
Non-Water Supply Well: el ft. 26—ft.
OMonitoring DR.-,ey ft. ft. 41
Injection Well: ft. ft.
:3Aquifer Recharge E)Groundwater Remediation 19.SAND/GRAVEL PACKif applicable)
:]Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3stormwater Drainage & ft. I
Experimental Technology []Subsidence Control ft. & I
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
-- , 47e,g
Geothermal(Heating(Cooling Return) 0Other(explain under#21 Remarks) FROM
To DESCRIPTION(colar hardness softfrack rain Sim etc.)
-
62 1 X IL
4.Date Well(s)Completed: 22 Well ID#
5 Well Location:
.Zh 3..
J744L,-,-
Facility/Owner Name Facility ID#(ifeppliGable) ft. ft.
op ft. ft.
/2a /
Physics Address,City,aA Zip ft. f,
21.REMARKS
unty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if ell field,one lattlong is sufficient) 01n, 22. ft
!-m- �- J N Lrl a W r, , 7
6.Is(are)the well(s)oPermanent or OTemporary Signature oircertified ntf Wei adrtor Date
1,
By signing this form,I hereby cart#5,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or [0140 with 15A JVCAC 02C.0100 or 15A AICAC 02C.0200 Well Construction Standards and that a
Ythis is a repair,fl/l out brown well construction information gn—derplain the nature of the copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: -7 � SUBMITTAL INSTRUCTIONS
6 9.Total well depth below land surface: - (ft-) 249. For All Wells Submit this form within 30 days of completion of well
For multiple wells list all depths(f&fferent(example-3@200'and 2@1001 construction to the following-
10.Static water level below top of casing: Division of Water ResourceS,Information Processing Unit
lfwater Level is above casing use
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: 1"144 above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc) f construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 11� Method of test: lo'&4-t 24c.For Water Supply&Iniecd6n Wells: In addition to sending the form to
0&1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 'LO-L completion of well construction to'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