GW1-2022-10111_Well Construction - GW1_20221110

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
K* it 14.WATER ZONES !
Well Contractor Name FROM TO I DESCR10MON /�.�
®Ig 41 ft. I ft. l (' L lU tt. ft.
NC Well Contractor Certification Number
15.0UTER CASING for multieased wells OR LINER f a liable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name © ft. / 9ft. 6 6—iq)V/
�9 t y C1 L t 16,INNER CAASSING OR TUBING eothermal closed-loon)
2.Well Construction Permit#: 1 ( 7v FROM TO DIAMETER THiC—Km m---T MATERIAL
List all applicable well construction permus(i.e UIC,County;State,Variance,etc.) ft. I in.
3.Well Use(check well use): It. ft-
in.
Water Supply Well: M SCREEN
FROM TU DIAMETER SLOT SIZE THICKNESS MATERIAL
Agriculttual [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) J?lBesidential Water Supply(single) —it. ft in
IndusWal/Conmlercial E3ReSidential Water Supply(shared) 13.GROUT
i—thrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: R /, ft 1 S%
Monitoring Recovery ft. C.f ft.
[it
Injection Well:
A uifer Recharge ft ft.
a
9 gGroundwater Remediation
uifer Storage and Recovery 19.SAND/GRAVEL PACK a licabie
A
q ge ry Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test oStormwater Drainage ft. ft.
Experimental Technology oSubsidencc Control ft. fL
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heatin Cooling Retain) Other(explain under 421 Remarks) FROM TO DESCRIPTION color hardness,sol0rock type,grain etc.
ft. fe' Z r-J
4.Date Wen(s)Completed:—�en EN ft 5—ft. 5 d XOC t
Sa.Well Location: R' 2 C'S--ft• 31 U e C 1Z
A U R A mob It fL ft.
Fajcility/OCwner Name Facility ID#(if applicable) ft. ft
��
7 �J C �l 1 `' O w-2i y,,,Lg4 ry r�J ft- ft
Physical Address,City,and Zip I R. fL .
AA A y(s d C e 21.REMARKS afl llraceeWS
Cow Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat(long is sufficient) 22.Certification:
N W Z'/f J12, —.2 —
6.Is(am)the wei(s) Permanent or OTemporary signature of Certi ued Well Contractor Date
By signing this,jorm,I hereby certify that the rvell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ON. with ISA NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
lfthis 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 thisform.
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:
t.�S— SUBMITTAL INSTRUCTIONS
9•Total well depth below land surface: 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Qa 200'and 2@J 00) construction to the following:
10.Static water level below top of casing: 0 (ft-) Division of Water Resources,Information Processing Unit,
#'wafer level is above casing,use"+" � 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method:_ �. j ) J) above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
138.Yield(gpm) �' Method of test: _ 24c.For Water Supply&Injection Wens: 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: 1 Amount: o Z 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 1 Revised 2-22-2016