GW1-2022-10385_Well Construction - GW1_20221115

WELL CONSTRUCTION RECORD(GW 1 Print Form
For Internal Use Only:
-
L Well Contractor Information:
David Hardy
14.WATER ZONES
WeIICOntractorName FROM TO DESCRIPTION
2906-A n rt
NC Well Contractor CertifiicationNumber {ft. / ft
Aqua Drill, Inc. 15.OUTER CASING for multi cased weirs OR LINER tf a ncable
FROM TO DIAMETER 7HIC ESS M RIAI.
Company ll ft.
2.Well Construction Permit#: � 1 •INNER C G OR TUBING Othermal closed-loo
List all applicable well to cotutructionpermits(i.e.UIC,Cortnh;State,f'ariaace,etc..) FROM TO
TO tk DIAMETER THICKNESS MATERIAL
3.Well Use(check well use): ft. rc in
Water Supply Well: 17.SCREEN
Agricultural [3MunicipaltPubiic SWTSI2:E FROM TO DIAMETER THICKNESS I MATERIAL
ft �
Geothermal(Heating/cooling Supply) Supply
�Residential Water Su 1 pp y(single) rt.Industrial/Commercial oResidentiat Water Supply(shared)
Ini ation IS.GROUT
FROM TO 6ATERIAL EMPLACEMENT METHOD&AMOUN-T
Non-Water Supply Well: ft, d ft
Monitoring ._..Recovery
Injection Well: ft. %
Aquifer Recharge ElGroundwaterRemediation ft. ft.
Aquifer Storage and Recovery OSalinity Barrier 19.SANWGRAVEL PACK of licable
Aquifer Test
FROM TO MATERIAL EMPLACEMBNTMETHOD
_ QfStormwater Drainage rt fh
Experimental Technology E3Subsidence Control
ft. ft
Geothermal(Closed Loop) OTracer
20.DRILLING LOG attach additional sheets if necessary)Geothermal(Reating/Cooling Return) Other(explain under#21 Remarks) FROl TO DESCRH TION coior,4erdness soiVrock e, roio siu etc.
ft. ?eft g
4.Date Wells)Completed Well ID# ft. —0 ft. -
Sa.Well Location:
©il- ft. e -
Facility/Owner Name v
Facility ID#(if applicable) ft. ft.
ft. ft. f .0_
l Add
Physicaress,City,and Zip ft.
? _ 21.REMARKS f N 0 V 1 r� 207
7
County Parcel Identification No. P
( 1M Irgoi'B1iS`3it11 t3*OGSv.�J[.ltY,l
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:(if well field,one at/long is sufficient)
r 7- TO/ N C �� 22. r'tication:
`� C� W
6.Is(are)the wells ermanent or Temporary Signature of Wetl ontrect ry
Date
7.Is this a repair to an existing well: Yes Anderplain
NO By sigrnng this fa•m,1 hereby that the well(.c)tvar(were)constructed in accordance
I"his it a repair,fill attf blown well constructio�:format lire nature ofthe c Py ofthis record ha,been prof vided5,4 to 1 e well owne��l Construction Standards and that a
repair under#21 remarks section or wt the back of this form.
23.Site diagram or additional well details:
S.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:
9.Total well depth below land surface: SUBMITTAL INSTRUCTIONS
(fL)
For mi NPIe'veils list all depths ifd Brent(exmnple-3(o�200 andz@Ioo) 24s. For All Wells: Submit this form within 30 days of completion of well
/l construction to the following:
10.Static water level below top of casing: (�G.�
If water level is above casing use"+ (ft•) - Division of Water Resources,Information Processing Unit,
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: - above,also submit one copy of this form within 30 days of completion of well
augc,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
13a.Yield(gpm)_ Method of test: ft, 24c.Foe Water SunDiy&Iniection Wells: In addition to sending the form to
I-Althe addresses) above, also submit one copy of this form within 30 days of
136.Disinfection type: Amount: 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