GW1-2023-01826_Well Construction - GW1_20230223

WELL CONSTRUCTION RECORD(GW 1) Print Form
For Internal Use Only:
1.Well Contractor Information:
David Hardy
14.WATER ZO
Well Contractor Name FROM TO NES DESCRIrl'ION
2906-A
NC Well Contractor Certification Number fI• ft.
Aqua Drill, Inc. 15.OUTER CASING for multi-cased wells OR LINER if a livable
FROM TO DIAMETER THICICN S MAT RL1L
Company Name ft. fL 7 � ]�
t R 2.Well Construction Permit#: ��' L� 16.INNER ING O TUBING thermal closed-1
�List all applicable well consnvction perm FROM To ,
its r.e.UIC,Covert}•,State.4ariance,elc.) DIAMETER THICKNESS MATERIAL
ft• ft. in.
3•Well Use(check well use): ft. f4 in
Water Supply Well; 17.SCREEN
Agricultural []Municipal/Public FROM TO DIAMETER SI UT SIZE TMCKNESS MATERIAL
Geothermal(Heating/Coofin Supply) ft• f4 in.
g PP Y) . Residential Water Supply(single)
IndustriaUCommeroial ft ft• In.
Residential Water Supply(shared)
Irri ation 18.GROUT
Non-Water Supply Well: FROM TO MATERIAL EMPLACEMENT METHOD&A1fOUNT
Monitoring ft• 7 S R C e
Recovery
In
Well: ft R.
Aquifer Recharge Groundwater Remediation fit• ft'
Aquifer Storage and Recovery Salinity Barrier 19.SAND/GRAVEL PACK if liceble
1� FROM TO MA7ERIA1. EMPLACEMENT METHOD
Aquifer Test C]Stormwater Drainage
Experimental Technology Subsidence Control ft. fz
Geothermal(Closed Loop) Tracer
20.DRILLING LOG attach additional sheet ff necessary)Geothermal(Heating/Cooling Return) IIOther(explain under#21 Remarks FROM TO DE IPTroN(color h,rdmess,sail/rock tyrain"�ft. / fr• dz..ec.
4.Date Well(s)Completed:
Well ID# R
'Aft.
5a.Well Location:11 ft
��4� G '!
Facft
ility/OwnerNName,/ Facility (ifap/plicable) ft. (t,
4ftysicallddr s,City,and Zrphr21.REMARKS
Parcel Identification No.(PIN)
5b.Latitude and longitude in
(ifwcll field,one laUongs sufficient)
1 deg(ees/tnlnates/seconds or decimal degrees:
3 L I 22.Certification:
6.Is(are)the welIrmanent or Temporary slgnatEfre of r emned Well Contractor
Date
By signing this form,1 hereby certify that the wells)was(were)constructed in arc
7.Is this a repair to an existing well: QYes or QNo with 15A NI02C.0100 or 15A NCAC 02C.0200 Well Construction Standar e
ds and that ordanc
!f this is a repair,fill out known well construction information and explain life 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 conshuction details. You may also attach additional pages if necessary.
drilled:
��9.Total well depth below land surface: 3 SUBMITTAL INSTRUCTIONS
For multiple wells list all depths ifdifferent(example-3(a)200'and 2Q100) (fit•) 24a.For All Wells: Submit this form within 30 days of completion of well
/,
construction to the following:
10.Static water level below top of casing: J O
lfwnler level is above casing,use"+- (ft.) Division of Water Resources,Information Processing Unit,
Il.Borehole diameter. (in.)�- 1617 Mail Service Center,Raleigh,NC 27699-1617
24b.For In•ecti 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
0,e.auger,rota cable,direct pus etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
S / 1636 Mail Service Center,Raleigh,NC 27699-1636
24
13a.Yield(gpm) Method of test:
;,/t✓T_____ c.For Water SunDly v.Injection Wells: In addition to sending the form to
136.Disinfection e L 0- the address(es) above, also submit one copy of this form within 30 days of
UAmonnt: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016