GW1-2022-10113_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Weil Contractor Information:
0 rmatio(nn: %5
V tl r 5 K i%ry""9 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
® ® 22/
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a llcable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name Q ft. 'eaft. /_S/ in ' /
16.INNER CASINGOR TUBING(geothermal closed-loop)
C/
2.Well Construction Permit#:5-0 '7 21—.J r- yL)U FROM I To DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UiC,Counh;State Parlance,etc.) ft. ft. in.
3.Well Use(cheek well use): ft. ft. in.
Water Supply Well: 17.SCREEN
Agricultwal FROM TO DIAMETER . SLOT SIZE HI TCKNESS MATERIAL
I[�Municipal/Public ft, ft, in.
Geothermal(Heating(Cooling Supply) fl
Residential Water Supply(single)Industrial/Commercial Residential Water Supply(shared) — ft. in.
18.GROUT
ln'i ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: © ft 62Qft. f s
Monitoring DRecovery ft. ft. Yl
Injection Well: ft. ft.
Aquifer Recharge []Groundwater Remediation
19.SAND/GRAVEL PACK tics6le
Aquifer Storage and Recovery i©ISalinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
NGeothermal FROM TO DESCRIPTION color,hardness,soi0rock to sim ete.
(Heating/Cooling Return) Other(explain under#2t Remarks) � ft. �
4.Date Well(s)Completed.& Well ID# J��o _
Sa.Well Location: DC) IL 0 ft. e
J Ca rte e),�Dej2S t �,C ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
600 lot i 11(r--PtqC1° r,i I l —...�.� ft.
' t,•r.�o !lt,
Physical Address,City,and Zip ft. ft. ECLIVED
4 f l�4 AAZC tQ 21.REMARKS county Parcel Identification No.(PIN) NOV A'
O V 1 Q 2022
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certiftca on: DWQ;WG
N W Z✓� ��'Z7
'
6.Is(are)the well(s) Rermanent or ©ITemporary Signature of Certified Well Contractor Date
By signing this farm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or r�o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
lfthis is a repair fill out!mown well construction information and explain the nature of the copy of this retard has been provided to the well owner.
repair under#21 remarks section or on the back of this form
23.5ite 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:
�1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �y 1 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdifferent(example-3@200'and 2@l001 construction to the following:
10.Static water level below top of casing. `' 6 (fL) Division of Water Resources,Information Processing Unit,
Yuuter level is above casing,use"++°°" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: C6 010 24b.For Injection Wells: In addition to sending the form to the address in 24a
A/1 IL Well construction method: tZ above,also submit one copy of this form within 30 days of completion of well
/ _ � 1 i(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Matz Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test::s,61 24c.For Water Supply&Iniection Wells: 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: Amount:I r r Z completion of well construction to the county health department of the county
where constructed
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016