GW1--01199_Well Construction - GW1_20240219

i. Print Form.`
WELL'CONSTRUCTION.REOORD(GW-11 For internal Use Only: . I'
L Well•ContractorInformation:
Chris King, 14:WATER ZONES
Well COnttaCtorName • FROM . . .TO , 'DESCRIPTION' •• -
2080-A S rt:'_< 6. E: .• .i's. .4i•PI Pl -
•
• NC Weil Contractor Certification Number•
• IS.OUTER CASING(for multi-cased wells)OR LINER Map Icable): -
Aqua:Drill,.Inc.. .• - 'FROM • .' TO• . • 'DIAMETER' THICKNESS MATERIAL- - . .
O tG fL / , 1'O .
Company Name 4. 6.74 'In-•.. .o..4/� .
(i '16.INNER CASING OR TUBING(geothermal doled loop) . . • -
-2.Well Construction Permit#:$'"-) / -t J eL J-'2 02 FROM •TO DIAMETER •THICKNESS .';MATERIAL. .
• -List all applicable null constntcl/on per mits,(l.e.. C,Coano%State:Variance,'etc.)... . ' IL.. . • ft. ,in.•
:3.Well Use(check well use): ft: R. ,in.:: .: • •
•
• Water SupplyWellr 17:SCREEN' . - • . - • .
. • •FROM 'TO• •.DIAMETER. SLAT SIZE. ' .THICKNESS' - MATERIAL
DAgricultural: alPublic.Munici •P. ft. ft. In:
'OGeothermal(Heating/Cooling Supply): '1 sidential•Water Supply(single) • - :ft - it - in.
QIndustrial/Cotnmercial .•°Residential Water Supply(shifted) .• ,Ig,GROUT
. fIrrigation. _ •FROM - • 'TO. 'MATERIAL I - -EMPLACEMENTMETHOD&AMOUNT.
Non-Water Supply Well: ft.- R •.
-'QMonitoring . . . . ' •DRecovelY ".ft. :ft..
Injection Well:.
DAquiferRcchargc DGroundwatcrRcmediation n i
QAquifer Storage and Recovery Salini Barrier' : 19.SAND/GRAVEL'PACK(If applicable)
: tY . . FROM' TO ••MATERIAL- - EMPLACEMENT METHOD.
DAquifer,Test' ' OStorniwaterDrainage • II. R:
DExperinientel Technology • OSubsidence Control .. .. ft.' . • ft.
is •
HGeo1need
Loop). . • 'OTmcer 20.DRILLING LOG(attach addlttonalsheets if necessary)' . .
Geothermal(Heating/Cooling Return) ( Other(explain under.#21 Remarks) .;FROM TO DESCRIPTION(colon-hardness.tallrockf e.train size.etc.)
ft: n". ++d CI ii
•
4.Date.Well(s)Completed�''q. '2 Well 1D#' . . _• R.. c5.'n• ; .i1{'�d •j2( K --
. 5a.Well Location:. iy�'- • l Oc.ft:. Bi :ei L'ri l-1 e•
fL • R..
. fir",t41 fin.XaM.•It .A.b.."�,
. Facility/Owner Name •Facility ID#(if applicable)• It.• • 'ft.' ; �-i c t.: /'ft
a.
`t
}. ' .l2 F6SI I IN 2nn1 .
.Physical Address,Ciity,:andZip fL ft.• L d tl t: •
411gn��oce .21.REMARKS . . •
County Parcel Identification No,(PIN) • .DMA O
56.Latitude and longitude In degrees/minutes/seconds or decimal degree: .
(if well field,ono bit/long js sufficient) 22:Certiflca n•'.
. . N q,.
6.Is(are)the.well(s) permanent •or'°Temporary • Signa arc of Certified• all.Con ctor ' J . Data
By signing this form;Thereby ccrtio,(rite the well(s).nus.(nerr)constnicted:in accoidance
7:Is this a repair to an existing well:' 111 Yes -or d.No aid,ISA NCAC 02C.0100 or'ISA MAC 02C.0200 Well Construction Standards and that a '
Phis is a repair,Jill out*noun Well consirudlori l rrnratinn and esplalitthe natur a of the copy'of this reebrd,has Been provided to the well owner.
repair under#21 remarlrs section or on Ihaback ofthisform.:
,23..Site diagram or additional welldetalls: • ' •
8:For Geoprobe/DPT or Closed-Loop Geothermal Wells"having the tame 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.aiso attach additional pages if necessary.
drilled
. ...SUBMITTAL INSTRUCTIONS . '
•9:Totalwelhdepth below land surface: / - • ' (ft.) 24e. For-Ali-Wells; 'Submit this form within 30 days:of'completion.of-well
For multiple wells list all depths if different(example-'3 200'and 2Q100) construction to the followingI '
10.Static water level below to of casing: Q I
. IfUhlerlevelIsabovecasing,are"p'' (ft.) Division of Water Resources,Infornietionl'rocessingUult,
•
1617 Mall Service Center,-Raleigh;NC-27699-1617'
11.Borehole diameter: (In.). -24b.- •For Infection Wells:-In addition•to sendingthe feria to the address in 24a
•• 11 -above,.also submit one copy of this form within 30•days of completion of well•
12:Well construction.method:'- I I2 • cIZi I'1 construction to the'following: j
(Le auger rotary,cable:direct push,etc. •
,
•
DIvlsionof Water Resources;Underground Injection Control Program;.
FOR WATER SUPPLY WELLS ONLY:'• •1636 Mail-Service Center,Raleigh,NC 27699-1636
.13a.Yield(gpm) . '� • • Method of test:-. l;I
'f (S j•01. . •24c.•For.Water Snooty&'Iniectiori•Wells:. In-addition to;sending the form to•.
tf the address(es).above,also•submit'one copy of this'form within•.30 days of
' • 1313:Disinfection type: 14 T 14- .Amount:l G. 6.Z. - • •completion of well.construction-to the county health.department of-the county
'where constructed.: • I.
•
Form GW-I North Carolina Department of Environmental Quality-Div'ision'of Water Resources 'Revised 2-22-2016'