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