GW1-2022-10086_Well Construction - GW1_20221104

WELL CONSTRUCHON RECORD!GW D
For Internal Use Only:
L Well Contractor Information:
,` K �✓ IA WATER ZONES
Well Comnnm Name PROM TO DaBLRIPTION
� 0 p ` R
NCW.11 Conhactor Certification Number R R.
Aqua Drill, Inc. 15.OUTER CASING fir mam W Is ORLINER ncable
FR/O�M TO DM TEUCKNISS MATERIAL
Company Name �t V R• U ' R � fa j G��'
2.Well Construction Permit#: � 1 R CASING OR TURRyfr esthvmal aimed-la
LRdlapPlicablewe/lec,Po -ion FROM To DMETER TmCKNESS MATERIAL
permt&fta UIC Caartry,S Ymionca M ere.J R R In.
3.Well Use(cheek well use): R R la.
Water Supply Well: 17.SCREEN
Agicultuml ®MwicipaVPubkc -ROM TO EE TRRTrR
mamgmst aLOT N6g MATERML
O. IL iL
Geothermal(HeatiogJCoolhtg supply) tesidential Water Supply(single)
IndushiaVCommerciai IL IL4
Itli anon QResidetmal Water Supply(shared) IL GROUT
Non-Water Supply Well: FROM TO MATXRML EMPLACEM6N'r METHOD&AMOUNT
OR � R S
Monitoring Recovery
Injection Well: R R
E
harge ElOrm-dwater Remediation tt• R
rage and Recovery Salinity Barrier 19.SAND/GRAVEL PACK k
t OSbrmwater Drainage FROM R TO R MATEBMI, aMPra METHOD
l Technology Subsidence Control R R
(Cbaed Loop) [3Ttacer XDRILLR4GLOG attachaddttiwal WeamH
eatin in get--- Other(ex lain under#21 R--im) FROM To DEECmPrrINH rotor ha,aiesawumrti ue
4.Date Well � }Z Q R. R.
Completed: �� � �^' Well ID# R R. d
clay
Sa Well Location: R c,ryp_ G a
fL OJ t.
Faeility/Owncr Name Faclity ino(ifapplicible) R R
a /
2635 r►�Ahi c-{anj > rz 1 lz � R R
shy—A 33,,CnY,and Zip
41 d Pi nw is C 21.REMAKES
NOV
County 7-1Identifidtion No.(PIN) DWQFSOG
Sb.Latitude and longitude in degrees/nibmtes/smonds or decimal degrees:
(ifrvcll field,one laVlong is,uffid,00
2L Cert_ Non: �1
N W S.Ts(are)ihe wen( ertmnent or ®Temporary Wgvenae-rcentfied Well m nhscr
Date
7.Is this a repair to an existing well: QYes or aNO dY riP679 a&foem,I hereby c.tyy dm the well($)war(were)mnHivcted ie is condos¢
w1M 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Corssnve[ian Slardards and that a
/(this it a repair,/1fl ma known wed mesbucd-n information and ewlaie die namm ofthe mPy-(this record bar been provided to the well owner.
repair under#21 ramarkr section or on the back rfth&form.
23.Site diagram or additional wen details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details a well
cruntmetioq Only I OW-1 is needed. Indicate TOTAL NUMBER of wells constructiou details. You may also attach additional drilled: pages if necessary.
�(9.Total wail SUBMITTAL INSTRUIONS depth below land surfs":� U� (R)
F naldplewdhlutall depths tfdigerent(eramp e-3®200'aadl®1007 24a. For All Wells: Submit this form within 30 days of completion of well
`l construction to the following:
IQ Static water level below top of easing; v (R)gwater kW is above caring,are^+': Division of Water Resources,Information Processing Unit,
6 1617 Mall Service Center,Raleigh,NC 2 769 9-1 6 1 7
- 11.Borehole diameter: (in.)
7 24b.For Intection Wells: In addition to sending the form to the address in 24a
1L Well construction method- /` r7; /J above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,duct push,efe) construction to the following:
EFORWAXEi SUPPL ONLY; Division of Water Resources,Underground Injection Control Program,
1636 Man Service Center,Raleigh,NC 27699d636
pm) Method of test: (nj �rt 1— 24n,For WaterSu"ly&IRieclio Well ; In addition to sending the fmm to
tlon the address(es) above, also submit one copy of this form within 30 daysof
type -R 7"H Amount-. 0 .2— completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Camlvu Depemnem of Pnvuemmenml Quality-Division of Water Resources
Revised 2-22-201 6