GW1--03724_Well Construction - GW1_20240621

WELL CONSTRUCTION RECORD(GW 11 i Print Form
For Internal Use Only:
1.Well Contractor Information:Welt t nn Li///1 T
� /*//e/if/ 14.WATER ZONES
hector Name
NC Wet Contractor Certification Number R' D
Aqua Drill, Inc IS.OUTER CASING(fur tonal-casedwells)OR LINER(if apl1eabie)
FROM I TO DIAMaTER THICICN MATE
Company Name 0 IL er in. I L ///J 2/{ .�},'�,
2.Well Construction Permit#: �/f�' 3 J 16.INNER CASING OR TUBING(geothermal l /'(�
_ f O `e9 dz.° FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pe mi s(i.e.VIC,Coiner,Sate,Variance,etc.) IL R. in. —
3.Well Use(cheek well use): R. ft. In.
Water Supply Well:
6 17.SCREENFROMAgriculturalAgriculturalFRa TO DIAMETER SLOT SIZE THICKNESS MATERIALQMunicipaUPublic R. H. in
°Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
°IndustrialCommercial R R- I°•
�Resideatial Water Supply(shared) _
',Irrigation
18 GROUT
TO
Non-Water Supply Well: FROM METHOD 4 AMOUNT
tit (7 s. ze^�Monitoring °Recovery f. � �•1t DC�.r'i,1 y�fR
0
Injection Well:
Aquifer Recharge DGraundwater Remediation ft.
Aquifer Storage and Recovery �sal�iry gamer 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL FA1t'LACEMENT METIiOD
Aquifer Test OStormwater Drainage R it
Experimental Technology °Subsidence Control R, — _
ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach a/dltia„d shawls If Deceuary)
Geothermal(Heating/Cooling Return)Return) �}Crcher(explain under#21 Remarks) FROMR. fO l, VESCIIFIO N(color,bantams va neck type.gran.lac,et�l
4.Date Well(s)Completed:6/7/2 Well Wit f/ it' 5-.
tV5 Weil Location: 2�•' 3 �$ �7,,— '7/r jL
A1...Z11l�t-1 L(co c J 7
Facility/Owner Name p Facility 1D4(if
aappplic/able) D. R. - •
33I'4 //5i % 4:wet',ii A I27tP(/� D. ft.
�'►;..\ _ < :)
Ph leaf Address,City,and Zip ft. rt. JUN
ZOZ
rt A�(�Z 21.REMARKS U
County J Parcel Identification No.(PIN) r k
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: LY"''*` ,
(if well field,one lat/Iong is sufficient) ^�� �j
3 <-7 7 2. N / 7• /s- I W 22 C ton: `°'.�J
6.Is(are)the well(s)gaPerauneot or Temporary Signature of Ceti'red Well Contra,
Date
7.Is this a repair to an existing well: QYes or By signing this form,I hereby cerr fy that the well(s)was(were)constructed in accordance
o with I SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construe-non Standards and that a
/f this Ls a repair,fill out known well construction information and explain the nature of the copy alibis record has been provided In the well owner.
repair under#21 remarks section or an 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 pug: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: 3 Z .5— (ft-)
For All Wells: Submit thin EMI] within 30 days of completion of well
For multiple wells list all depths ifdifferent(example.3(2200•and 2(a)100) ons c
/,- construction to the following:
10.Static water level below top of casing: T C (ft.)
lfnoter level is above casing,use"+' Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)
24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: /t/' Ale#�,/ above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) !!y 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) Method of teat: �
13b.DDisinfectiontyp i G 'L• up
24c.For Water Smile&(election Wells: in addition to sending the form to
e, �� /tP �—� w ✓ the address(es) above, also submit one copy of this form within 30 days of
�mount: [ d completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Dep
artment of Environmental Quality-Division of Water Resources Revised 2-22-2016