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HomeMy WebLinkAboutGW1--00414_Well Construction - GW1_20240116 . r Print Form WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I~ ' i 1.Well Contractor Information: ! Chris King •14:WATER ZONES t Well Contractor Name FROM TO DESCRIPTION • 2080-A CIO rt: Ci l ft: 020 i G•Pe eI ft. ft. NC Well Contractor Certification Number 15.OUTER CASING(for multl.cased wells)OR LINER(if ap licable) Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MAARIIAL V0 ft,C� ft. 6,/is In. i/�g LJ.4)1/ Company Name �� / �? 16.INNER CASING OR TUBING(geothermal closed-loop) 2.Well Construction:Permit#. 4� L.AJ J PROM TO 'DIAMETER THICKNESS MATERIAL List all applicable well cons:me/ion permits(i.e.WC.Cotutp:State.Variance.etc.) • fr: ft. in. • 3.Well Use(check well use): ft. ft. In. Water Supply Well: 17.SCREEN Agricultural FROM TO DIAMETER .SLOT SIZE THICKNESS MATERIAL 8 DMunicipal/Public . ft. ft. In. Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft, ft. in. Industrial/Commercial DResidential Water Supply(shared) 18:'GROUT. irrigation FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: D it, go IL iN J4c c ir'1 i% p 5 Monitoring Recovery • rt. R. T Injection Well: ft. fr.A Aquifer Recharge °G roundwater Rcmcdiation 19.SAND/GRAVEL PACK(If applicable) Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD Aquifer Test QStormwater Drainage ft. ft. Experimental Technology °Subsidence Control ft. ft Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary) Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM. TO. DESCRIPTION(color,hardaee aal#roek type,grain atze eta) 4.Date Well(s).Completed: � .S /I Ll We11ID# © ft. fr. I G( �t (AV .32.Well Location:, SigR' CO ft. ofj C Giz,4 I/4.c 9/O ft. /'00 fr• Slaved. Act -fliZarcur9 ret?cC �fFacility/Owner Name a W Facility lD#(if applicable) ' 90 R. J8r D• 1�{)0C 6-imu tc 9709 t®R` -3�?MeS el /� R. ft. vs (.T '1 Physical Address,City,and Zip ft. ft. _ hei a 21.REMARKS Pi'r.. . County (e' Parcel Identification No.(PIN) , r $ 9 n Sli:Latitude and longitude in degrees/minutes/seconds or decimal degrees: i'�N I. 2!� Q (if well field,one lat/long is sufficient) 22.Certification: N llh`turAIri iVI Psi;,; W43 ii�` DWQ413 7`O -,Z C/ 6.Is(are)the well(s)gPermanent or ITemporaty Si nature of Certified Well Connector Date �(� By signing this form.I hereby cert/fy that.the well(.)was(were)constructed in accordance 7.is this a repair to an existing wells IN Yes or f ° 't with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 iVell Construction Standards and thata If this is a repair,fill ant known well construction information and explain the nature of the copy of this record has been provided to the well owner. repair under#21 remarks section or on the back gfibis 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: I 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 ifd/fferent(example-3(a 200'and 2 a 100') COconstruction to the following; I. 10.Static.water-level below top of casing: (ft.) Division of Water Resources,iInformation Processing Unit, If water kiwi is above casing,use"+" • 1617 Mail Service Center;Raleigh,NC 27699-1617 11.Borehole diameter: CO (in.) 24b.For Infection Wells: In additio to sending the form to the address in 24a A II .J l above,also submit one copy of this Pomt within 30 days of.completion of well 12:,We11 construction method: /7/ t7Ile (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 13a.Yield(gpm) 420 . Method of test: 51.q H 4- 24c.For Water Supply&Infection 1Welis: In addition to sending the form to a!7// the address(es) above, also submit dineI copy of this form within 30 days of type:e: !'I j. Amount: /e 0 Z. completion of well construction to the county health department of the county where constructed. fl i Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources , Revised 2-22-2016