GW1-2023-02089_Well Construction - GW1_20230307

WELL CONSTRUCTION RECORD(GW-b) For Internal Use Only:
1,Well Contractor Innf`ormation-
Ramaw 14.WATER ZONES
Well Contractor Name FROM -,TOI DESCRIPTION
Is ft. ft. Q i 1 t
ft.NC Well Contractor Certification Number ft.
15.OUTER CASING for In! li�ased wells OR LINER if,, livable
Aqua Drill, Inc. FROM TO DIAMETER I THICKNESS MATERIAL
_ c .f CompanyNeme ft. ft /,!fC in.
j ] rf_ 16.INNER CASING OR TUBBIING. eothermal closed-too
2.Well Construction Permit#:E tb P A2 6 E) Q�3 FROM To I DIAMETER I TRICKNEss I MATERIAL
List all applicable well concstmctlon permits(i.e.UIC,County Stat4 Variance,etc.) ft. ft in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17—SCREEN
FROM TO DIAMETER ..SLOTSIZE I THICKNESS I MATERIAL
Agricultural [3MunicipaUPublic ft ft.
Geothermal(Heating/Cooling Supply) ,Residential Water Supply(single) fr. ft. in '
IndusiriaUCommeroial esidential Water Supply(shared)
18.GROUT
Uri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well; 0 "- 2J it _geA ko; ,
:)Monitoring [-Recovery ft. —ft.
Injection Well:
A fifer Recharge ft. ft.
- � g �CnoundwaterRemediation
Aquifer Storage and Recov 1 19.SAND/GRAVEL PACK if a liwble
�Y 0SaltnityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
ft
Aquifer Test oStornawater Drainage It-
Experimental Technology E3Subsidence Control ft I ft.
6 'Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessa
rvl
Geothermal(Heating/Cooling Retum) Other(explain under#21 Remarks) FROM To uESCR�IPTION(color,hardness,soi0rack rain size,etc.
� ft
9 . ft c / t
4.Date Well(s)Completed/_z�_IZ3 Well ID# tt go ft lAA 0j -zo K
5a.Well Location: ft. d—E t
ft ft.
)Faccility/OpwnerName r Facility ID#(ifapplicable) R• ft.
Physical Address,City,and Zip ft. ft
t 21.REMARKS
County I Parcel Identification No.(PIN) I �AR 0 " �^
-5b.Latitude and longitude in degrees/minuteslseconds or decimal degrees: '-- -c>._-n , ;, „ �!1,;4
(ifwcll field;one lattlong is sufficient) 22.Certifica' n: f v`:'ot y'�r
6.Is(are)the weil(s) Permanent or IOTemporary Signature of Certified Well Contractor Date
By signing thiv form,I hereby cerlify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or4nNo
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200{yell Construction Standards and that a
Ifthis is a repair,fill out known well caistuc;ion htformalion and plain the,nature of the copy ojthis 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 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: 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@1001
�- construction to the following:
10.Static water level below top of casing: 7 (� (ft) Division of Water Resources,Information Processing Unit,
ljrvater level is above cooing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
il.Borehole diameter: (fit.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method- /� J�) above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.r construction to the following. i
FOR WATER SUPPLY WELLS 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&Injection Wells: In addition to sending the form to
p the address(es) above, also submit one copy of this fort within 30 days of
13b.Disinfection type: Amount Q completion of well construction to tire'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