GW1--03731_Well Construction - GW1_20230602

i
Print Form.
WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A 7G ft. ft 6-1 F,
ft. It.
NC Well Contractor Certification Number
15.OUTER.CASING for malti cased wells OR LINER if a licable .
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name
fL ft in.
.21
i ..M.1NNER CASING"OR.TUBING eottierma]closed-loop)
2.Well Construction Permit#: l Q FROM To D R THICKNESS MATERIAL
List all applicable xv11 cmrstruction permits(i.e.UIC,County,State,Variance,eta) ft ft in.
3.Well Use(check well use): ft tt in.
Water Supply Well: _17.SCREEN FROM TO DIAMETER P SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft, - ft is
Industrial/Commercial DResidential Water Supply(shared)
I GROUT::. .. .
hTl atlOII FROM TO MATERIAL' EMPLACEMENT METnOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring DRecovery ft ft
Injection Well:
A uifer Rechar ft ft
e.
q Recharge. Remediation
Agtrifer Storage and Recovery Salini Barrier 19:SAND/GRAVEL PACK if a' licablc7--777-7-7777
_ -.. -
FROM I TO MATERLAL EMPLACE6IENTMETHOD
Aquifer Test DStormwater Drainage ft- ft
Experimental Technology [)Subsidence Control ft ft
Geothermal(Closed Loop) DTmcer 10.DRILLING LOG attach additional sheets if necessary)
:ilGeothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION rotor,hardness,soil/mck a rain sae,ete)
�V ft.
4.Date Well(s)Completed: p, Well ID# �+d�- ( ft ft
5a.Well Location: t l ft. ft
Facility/Owner Name Facility ID#(if applicable) ft• ft
yy a)
11.uo X E191zM 1Z0 &10od IC?'+ F +� fr. it ll1 � d
Physical Address,City,and Zip t ft ft
K— 11 21.REMARKS ^
County Parcel Identification No.(PIN) 1Z� 1 -a ED e-. Z
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: t Cj
N l `
6.Is(are)the well(s) ermanent or OTemporary Signature ofCertified Well Contra for Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or [3No will'15A NCAC 02C.0100 ar ISA NCAC 02C.0200 We11 Conshuction Standards and that a
If this is a repair,.till out known well construction information and explain the native of the Copy of this record has been provided to the well owner.
repair raider#21 remarkv section or on the back of thisform.
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 GN'V-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: :� (ft) 24a• For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@100)
construction to the following.
10.Static water level below top of casing: 0 water level is above casing,rise"+" (ft.) Division of Water Resources Information Processing Unit,
If g t,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) r 24b.For In•ection Wells: In addition to sending the form to the address in 244
12.'Well construction method: /�(�L t�lZ��1 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 WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
1 �13a.Yield(gpm) Method of test: t } 24c.For Water S,unoly&Tnjection Wells: 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: Amount:_�� Q 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