GW1-2023-01697_Well Construction - GW1_20230214

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WELL CONSTRUCTION RECORD(GW-I) For Internal s Only:
1.Well Contractor Information:
David Hardy 14.WATER-ZONES
Well Contractor Name FROM TO DFWBML-02
2906-A ft.
FEB ft. ft.
NC Well,Contractor Cedification Number
Aqua brill, Inc. ulr"'." 15.OUTE CASING for multi-cased wells) LINER(ifunplicablo—,
FROM TO DIADr
Ess MATERIAL.
5:1-sl
CompanyName ft.
X.-INNER CASING OR TUBING(Peothermal closed-loon)
FROM 0
2.Well Construction Permit I( THICICNESS I'.MATERIAL
I DIAMETER
List all applicable well construction permits cf.a UIC,Count};State.Variance,etc.) ft. f4 in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
:)Agculural FROM To DIAMETER I A,TAT QT7V iTHJ-IV-S IMl"—.—.1i cpauic It. tt. I in.
:IGeothermal(Heating(COOHngSupply) jffResidential Water Supply(single) ft. ft. In-
31ndustriaUCommercial DResidential Water Supply(shared) 18.GRO
UT
JIrrigation FROM TOP �WTEU* E14 EI%MNTMLM,!&AMOUNT
n-' it V it_ e,M
NOR-Water Supply Well:
Monitoring DRecovery & ft.
Injection Well:
ft.
Aquifer Recharge DGroundwaterRemediation
19.SAND/GRAVELPAC rifavoIicable)
quifer Storage and Recovery oSalinityBarrier FROM TO MATERIAL �EMPLACEMENTMETHOD
3Aquifer Test [3Stormwatcr Drainage ft ft. I
:]Experimental Technology 0Subsidence Control ft ft.
3Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets ifnecessary)
_lGeothermal(Heating(Cooling Return) L11Other(explain under#21 Remarks) FROM TO DESCIUPTION(color.hardness,saftfrock tYpe,grain sL74 OCT—
'e�;ft. ft..—
4.Date Well(s)Completed:. —5'—q-3WeHlD# ft R111", ft.
C71W b
Sa.Well L tio'" fk
it.
Facility/Owner Name Fa i ID#(ifapplicable) ft.
ft. ft.
Physical Address,City,end & •
-1-aJ ki/-1 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one JaVlong is sufficient)
Z 4:7-7 N I 3�— W
6.Is(are)the well(s)CIPermument or DTemporary Signature of t ate
By signing this
form,
I hereby carfi_&a the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ONO with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Fthis Is a repair,fill out known well construction h1formationfia'erplain the nature ofthe copy afthis record has been provided to the well owner.
repair under#21 remarks section or on the bac1c 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 ofwells construction details. You may also attach additional pages ifnecessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For multiple wells (ft) 24a.For All Wells Submit this forrit within 30 days of completion of well
list all depths irdifferent -3@ 200'aiz d2@100)
construction to the following:
10.Static water level below top of casing:.
If water level is above casing,use Division of Water Resourcesq;,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter.
24b.For Iniection Wells: In addition to sending the form to the address in 24a
12-Well construction method: above,also submit one copy of this form within 30 days of completion of well
-- I I
(i.e.auger,rotary,cable,direct push,ate.) construction to the following:
FOR WATER SUPPLY WE ONLY:- Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) v Method of test: 24c.For Water Supply&Iniection Wells: In addition to sending the form to
e4 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: I r. t 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