GW1-2023-00766_Well Construction - GW1_20230112

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
L Well Contractor Information:
David Hardy 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTIO
2906-A / ft /20 IL
�16 ft. t: U
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER tf a licable
Aqua Drill,Inc. FROM To Du THICKNESS MAT
4. ft. ft.
Company Name
��y` I&INNER CASING OR TUBING(geothermal closed-IR
2.Well Construction Permit M 1 ,1 1 FROM TO DIAMETER TFllCKNESS MATERIAL
List all applicable well construction permits(i.e C,County,State,Variance,etc.) ft. % in.
3.Well Use(check well use): ft. fL in.
Water Supply well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TRICKNESS MATERIAL
Agricultural E3Municipal/Public ft. ft. in.
-Geathennal(Heating/Cooling Supply) IgResidential Water Supply(single) ft, ft, in.
Industria/Commercial 'iDResidential Water Supply(shared) 18.GROUT
irrigation FROM I TO TE EMPLACEafENT1%1ETI10D&At410UNT
Non-Water Supply Well: ft• ft jr) l0 d(1/��
Monitoring [)Recovery ft. ft
Injection Well:
ft. ft.
` .Aquifer Recharge pGroundwaterRemediation
19.SAND/GRAVEL PACK ifapplicable)
Aquifer Storage and Recovery .Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD .
Aquifer Test OStormwater Drainage ft. &
Experimental.TechnoIogy OSubsidence Control ft. ft
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Wit.
DESCRIPTION color,hardoem soi0rock in size,etc.)
Geothermal(Heating/Cooling Return) I Other(explain under#21 Remarks) ft4.Date Well(s)Completed:��7-Welt Wff ft. l
5a. ell Location:J
1. -a .7 i
Facility wnerName Facility ID#(ifapplicable)
M ft
ft. ft
Physt ft. ft
Address,City,and Zi
r f /� 21.REN ARKC +•�L'Ji `.=5'�i::
County !(%r Parcel Identification No.(PIN)
5b.Latitude and longitude in,degrees/minutes/seconds or decimal degrees:
(ifwell fl9ld,one lattlong is sufficient) 22, rtificatio
6.Is(are)the wells)'' ermauent or i3Temporary SigrZdure of Certified Well Contraefo Date
By signing this from,I hereby cerlJ•that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or [RNo with 15A NCAC 0C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis fs 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 921 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobet'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: .^ (R) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if d{'ferent(example-3@200'aannd 2@1003 construction to the following.
10.Static water level below top of casing: �L� (ft.) Division of Water Resources,Information Processing Unit,
Ifivater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (in) 24b.For Infection 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: construction to the following:
(i.e.auger,rotary,cable,direct push,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Matz Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 67 Method of test: 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the addresses) above, also submit'one copy of this form within 30 days of
13b.Disinfection type: T�? ej 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