GW1-2023-01786_Well Construction - GW1_20230223

WELL CONSTRUCTION RECORD(GW 1) For Internai Use Only: Print Form
I.Well Contractor information:
David Hardy 7
14.WATER ZONES
Well Contractor Name FROM TO DESCR1PTtUN
2906-A " i ft• L 't _
NC Well Contractor Certification Number ft. ft
Aqua Drill, Inc. 15.OUTER CASING f lts OR LINER if ap cable
FROM TO Df ETER THIC 'ESS MATERIAL
Company Name ft• _ ft. ia. '7
f L li
y �t y' 16 INNER CASIN G OR TUBING eothermal Boreddoo
2.Well Construction Permit 7- /` FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. It. in.
3.Well Use(check well use): tt. ft. in.
Water Supply Well: 17.SCREEN
Agricultural []Mumicipal/Public FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. la.
Geothermal SHeating/Coolirlg Snpply) esidential Water Supply(single)
IndustriaVCbmmercial ' . ft ft. In.
esidential Water Supply(shared) IS.GROUT
Irri ation
FROM TO MATERIAL EMPLACEMENT METHOD&AM UNT
Non-water Snpply well: ft. 7 u
Monitoring ; ✓
Injection Wel6 r
Rocovery ft. ft o
Aquifer Recharge L•_ oGrotmdwater Remediation ft.
Aquifer Storage and Recovery Salinity Barrier 19.SAND/GRAVEL PACK ncabk
FROM TO MATERIAL, EMPLACEMENT METHOD
Aquifer Test oStormwater Drainage ft. flu
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional shears if ne
Geothermal Heating/Cooling Return) 00ther(explain under 421 Remarks) FROM TO DFSC PTION color,hard soWroek s, rain; ato
ft. ft. ! L 4,
l G L
4.Date Well(s)Completed: `2�' ell ID# ft, G'ft. ! ` �/
Sa Well Location: )ft• ft C
l \L'611.1 7k. ft.
l
Facility/Owner Name Facility M#(if applicable) D• ft.
� J
Physical Addross,Crty,and Ztp ft. It.
21.REMARKS
County Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient)
N r )� �Z 22. tification.
.W �
L t -
6.Is(are)the well(s) rmanent or Temporary Si tore J eriffi ell Contractor," - p t
7.Is this a repair to an existing wen: 0Yes or QNa- Blthh15A NCAC 02C.01h00 elreb or 15A NCAC102C.0200 led
Wethe well(s) ll Conss(wrtruct Drat Standards and that e
If this is a repair,fill out known well construction information and etplaia the nature of the copy of this record has been provided to the well awner.
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-I 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: A L`I'
For multiple wells list all deprhsifderent(examp/e-3(r320p•an @100) (ft') 24a. For All V1'ells: Submit this form within30 days of completion of well
construction to the following:
10.Static water level below top of casing: (�)
Ifwater level is above casing,use"+^ Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. � (in.),
24b.For Injection 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.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY 7LLS ONLY: Division of Water Resources,Underground Injection Control Program,
13a.Yield(gpm) Method of test:
1636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Supply&Injection Welts: 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: l mount: completion of well construction to the county health department of the county
where constructed.
Form G W-1 North Carolina De partment of Environmental Quality-Division of Water Resources Revised 2-22-2016