GW1--03180_Well Construction - GW1_20230505

WELL CONSTRUCTION RECORD(GW 1) For internal Use Only: Print form
I.'"'ell Contractor Information:
Chris King
14.WATER ZONES
Wcll Contractor Name FROM TO DESCRIPTION
2080-A q6 ft
NC Well Contractor Certification Number lv ft ft
15.OUTER CASING(for multi-eased wells OR LINER if a ticable
Aqua Drill, Inc. FROM TO DLAME'alt THICKNESS MATERIAL
Company Name ft. ft / S!� in. j�q !
`, 16.INNER CASING OR TUBING eothermai closed-lao 2.1Ve1!Construction Permit#:-5 7 f/(a1 C i�f ) FROM TO D[AMETER THICKNESS MATERIAL
List all applicable bell construction permits(i.e.U1C Counn.,State,Variance etc.) ft. ft. in.
3.Well Use(check well use): ft.
rN
Supply Well: 17.SCREEN
ultural FROM TO DLAMF.TER SLOT S[ZE THICKNESSS MATERIAL
QMunicipaUPublic ft• ft.
hermal(Heating/Cooling Supply) Residential Water Supply(single)
ft- ft. in.
striaUCorrmtercial Residential Water Supply(shared)
tion 18,GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ater Supply Well;
itoring Recovery
on Well: ft• ft.
fer Recharge DGroundwaterRemediation ft.
fer Storage and Recovery DSalinity Barrier t9.SAND/GRAVEL PACK(if a Dcable)
' TO MATERIAMENTMETHOD
fer Test QlStormwaterDminage ft trimental Technology Subsidence Controlermal(Closed Loop) DTracer 20.DRILLIG LOG attsch additional sheets if necessary)
ermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,h�,dne:�soiueorx Twlq rYia size,et[.)
C-i y
4.Date Weil(s)Completed:4C �C ,C 3 Well iD# ft.
�� f
tJct 1l �'Sa.Well Location: C IC
— ft ft. -
ft. ft.
(Faciillity/Owner Name Facility ID#(if applicable) ft. ft.
S!1- Sid j Y m C r I\ ! i 1 l<—C; —ft. ft SE
Physical Address,Citv,and Lip ft• ft
a v
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreeslminutes/seconds or decimal degrees: ,
(if'veil field,one lat/long is sufficient) �� �r
22.CertiScatia
tv M,
6.Is(are)the well(s)6ermauent or DIremporary St.--
ie uu c ofCertified We1lConrmcto
[e
7. r,.{ By si,"ing'his form,1 hereby certo,that the ivell(s)was(were)constructed in accordance
f Is this a repair to an existing well: Dyes orljiC INo with ISA NCAC 01C.0100 or ISA NCAC 02C.0100 Well Co
rcrtruction Standards and that a
If this s u repair,fill out latouai wel!cortstnrction information explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remur�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 constntction details. You may also attach additional pages if necessary.
drilled:
9.Total well depth below land surface: 1 g s` SUBMITTAL INSTRUCTIONS
(ft.)
For multiple wells list all depths if different(e_rample-3WO0'and 2®1001 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
If
10-Static water level below top of casing:. _ C)
enter level is above casing,Ilse ,+,, (ff) Division of Water Resources,information Processing Unit,
(in-)
11.Borehole diameter: �?
1617 Mail Service Center,Raleigh,NC 27699-1617
24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method:—4!iZ d K t above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct pusb,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
24
13a.Yield(gpm) Method of test: {� i(, in c. For Water Supply&Injection Wells: In addition to sending the form to
13b.Disinfection type: C+— '-' the address(es) above, also submit one copy of this foam within 30 days of
Amount: _ 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 2-22-201 fi