GW1--03179_Well Construction - GW1_20230505

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WELL CONSTRUCTION RECORD(GW-1,) For Internal Use Only:
J.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM To DESCRIPTION
2080-A 7 i R- � fL —�}
Cn
ft. ft.
NC Well Contractor Certification Number _
15.OUTER CASING(for multi-cased wells PUMA,
tf a licable
Aqua Drill, inc. FRODt TO DIAMETER. THICKNESS MATERIAL
ft. ft j` in
Company Name . 1 t o Ll
(Jr 16.INNER CASING OR TUBING( cothermal closed-loop)
2.Well Construction Permit#: %(U�1 �(�•,� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft, ft.
3.Well Use(check well use): ft. ft.
rNon-Water
upply Well: 17.SCREEN _
FROM TO DIAMETER SLOT SIZE TAICKNF.SS \lATF.RIA[.
ltural DMunicipal/Public R. ff in. —
rmal(Heating/Cooling Supply)i�Residential Water Supply(single) ft, ff. in.
nal/Commercial Residential Water Supply(shared) —
Ls.GROUT
ion FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ter Supply Wedl:ring Rft.
n Well:r Rechar e ft. ft.
g Groundwater Remediationr Storage and Recovery Salinit Barrier 19.SANDZGRAVEL PACK if a tp icab(e�
y FROM TO MATERIAL_ EMPLACFMENT METHOD
Aquifer Test [3Stormwater Drainage It. fr.
Experimental Technology [DSubsidencc Control fL fL
Geothermal(Closed LOOP) Tracer 20.DRILLING LOG attach additional sheets if neemary
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TTo DESCRIPTION(color,hardne s,saWcock t e, ra)n sue etc.)
ff 6 ft' Ed-
4.Date Well(s)Completed: /—27 _2__'�Vell ID# ft• ft. S t1C6C
Sa.Well Location:
Facil/ity/Owne�rtName Facility lDt?(ifapplicable) ft• ft � r�'Y —V
IL
Physical
Address,City,and Zip ft. ft. ►1
21.RE—MARKS T
County _. •;� t f.
Parcel Identification No.(P1N) �t"
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _
(if well field,one latllong is sufficient) 22.Cerdfle lion:
6.Is(are)the wcll(s�.Permanent or Temporary Signature ofCertt led We 1Con for Date
�N� By signing this form,i hereby certify that the wells)was(here)constructed in accordance
7.Is this a repair to an existing well: E)Yes or Eg& with 15A NCAC 02C.0100 or IS-4 NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known:well carstrucrion information and explain the nature of the copy of this retard has been provided io the well owner.
repair under P21 remarks section or on 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:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: sJ L� (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@1001
construction to the following:
10.Static water level below top of casing: c (ft.) Division of Water Resources,Information Processing Unit,
ljrmter level Ls ahove casing,use"+"
/ 1617 Mail Service Center,Raleigh,NC 27699-1617
l 1.Borehole diameter. (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method:_/ %j jZ d iz i t! 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 Matz Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) / Method of test: '{ 24c.For Water Suuoly&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: Amount:�s (Mj L completion of well construction to the county health department of the county
where co acted.
rormGW-1 North Carolina Department of Environmental Qual
ity ty-Division of Water Resources Revised 2-22-2016