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HomeMy WebLinkAboutGW1-2023-00731_Well Construction - GW1_20230113 Print Form WELL CONSTRUCTION RECORD(GW-1) For internal Use Only: 1.Well Contractor information: Chris King 14.WATER ZONES Well Contractor Name -^ ,`'�.,� ?�` FRUM TO DESCRIPTION I S � ft -L� t NC Well Contractor Certification Number J A N 1 2023 15.OUTER,CASING for multi-med wells OR LINER rf a licable Aqua Drill, Inc. FROM To DIAMETER TfIICK,7NEss MATERIAL Company Name Ili>>c:,;.w,_: � ft. 27 ft. ia- S /�-21 PI v,C rt a..o1i;zp• 16.INNER CASING OR TUBING cothcivral dosed-loo 2.Well Construction Permit#:C.t7l_ �CoC ���V FROM TO DIAMETER THIC)CWSS MATERIAL List all applicable well construction permits(i.e.UIC,County,State,Variance.etc.) ft• ft. t°' 3.Well Use(check well use): ft. fL in. Water Supply Well: 17.SCREEN FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL Agricultural Municipal/Public fL ft, in. Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. f Industrial/Commercial DResidential Water Supply(shared) 18.GROUT Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: 0 tL ft- - Ut Je— C in 1 0 S Monitoring pRecovery ft. ft. Injection Well: ft. it Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK rifapplicable) Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD _ Aquifer Test DStonnwatcr Drainage fL & Experimental Technology [3Subsidence Control ft. ft Geothermal(Closed Loop) Tracer 20.DRILLING LOG attachradditional sheets if necessary) FROM TO DESCRIPTION mlor,hardness,miltrmk e, in A etc. Geothermal(Heating/Cooling Re�t^um Other(explain under#21 Remarks) k or 4.Date Well(s)Completed: -J Well ID# (� tt, -26 k. S vd Re d 5a.Well Location: 70 "' —2 GJJift. (UC t i ft. fL fL Facility wirer Name Facility ID#(if applicable) 4) `I _'RV-)jAJ j-ji20 12 A fL fL Physical Address,City,and tZip fL ft.. ��M A k A 1'- 1 21.REMARKS County I Parcel Identification No.(PIN) 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one lat/long is sufficient) 22.Certifies'on: N W 6.Is(are)the well(s)&Permanent or OTemporary Signature of Certified Well CoContracm Date By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance 7.Is this a repair to an existing well: [3Yes or Mo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a If this 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 this form. 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary. drilled: �^q SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: (ft•) 24a.For All Wells: Submit this form within 30 days of completion of well For multiple wells hart all depths if different(example-3`a 200'and 2@100) construction to the following: 10.Stadc water level below top of casing: J^r) 010 Division of Water Resources,Information Processing Unit, Ifwater level is above casing,use-+" 1617 Mail Service Center,Raleigh,NC 276994617 11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a above,also submit one copy of this,form within 30 days of completion of well 12.Well construction method: 1 I?- (Z i construction to the following: (Le.auger,rotary,cable,direct pushy etc.) Division of Water Resources,Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 13a.Yield(gpm) tZ Method of test: S �/ 24a For Water Supply&Injection 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: j 0 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 Revised 2-22-2016