GW1--03763_Well Construction - GW1_20240621

ELL CONSTRUCTION RECORD GW 1) Print form
W
I For Internal Use Only:
1.Well Contractor Information: ,/ J
— 1'aiz n Z/ ` /v/`r
ivy 10.WATER ZONES Well Can'ractor Name PROM TO
�j'/f DESCRIPTION <�J
NC Well Contractor Cenification Number ft. ft. y
Aqua Drill, Inc IOUTER CASING(for )OR�RUlna )
DIAMETER ' THICKNESS MATEJUAL
Company Name ft. I e7 ft• 11� la ly t eve_._
2.Well Construction Permit f!: -i /410 1 INNER tCA`S C OR TUB G eothermal
List all applicable well construction permits(i.e.UIC,Corustv,State,Variance,etc.) ft TO R DIAMETER THICKNESS FROM L.
In.
3.Well Use(check well use): ft. ft — in
Water Supply Well: 17.SCREEN —
°Agricultural °Municipal/Public PROM TO DIAMETER SLOT SIZE TIUCKNESs MATERIAL
Geothermal(Heating/CoolingSupply) ft' rt. in.
�Resitlential Water Supply(single)
Dlndustrial/Commercial R ft. la
�Residemial Water Supply(shared) ag,GROUT
"Irrigation FROM TO
Non-Water Supply ft. TEt ►• est Pivr Well: 77;1:7
aMonitoring Dft. Lo <<,,, �t 4J eaf.Recovery ft
Injection Well:
Aquifer Recharge OGroundwater Remediation ft' ft.
Aquifer Storage and Recovery °Saiiniry Barrier 19.SAND/GRAVEL PACK Ofspptieable)
OAquifer Test FROM TO MATetuaL EMPLACEMENT METHOD
OStormwater Drainage ft, rt.
Experimental Technology Subsidence Control
ft. _
Geothermal(Closed Loop) °Tracer M DRILft.LING LOG(attack additional sYssr rasnesary)
Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) PROM TO ttEsc e.rtYs.,sdYtodt b tr ee. ait sire eta)
4.Date Well(s)Completed:6 l Well ID# ft, ,.)rt.
5a.Well Location: gk
ft. ft.
ft. ft.
Facility/Owner Name Facility 1 tf applic le) R• (L
1
�. y.Z. ft. ft.
Physical.A City,and Zi ft, ft. 1
<:,:ec..4,vdy 4041 e-4-1 7 1
IC• I '40fl 21.REMARKS
County
Parcel Identification No.(PIN) Dyties iCAi
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
�^4 `� /�e , 22. fiend : ! l��
. ", N W. i W ' I[ !t 6.Is(are)the well(s)OPermanent or j'remporary Si of certified Wel era r 7214-
Date
By signing this form,I hereby certlf},that,he wells)war(were)constructed in accordance '
7.Is this a repair to an existing well: ®Yes or )4o with 1 SA NCAC OIC.0100 or ISA NCAC OZC 0100 Well Construction Standards and that a
If this Is a repair,Jill out known well construction infosvratlon and explain the nature of the copy of this record has been provided to he well owner
repair under#21 remarks section or an the back of this form.
23.Site diagram or additional well details:
S.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:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2 ,7
'di erent(example-3 (ft) 24er For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths
tl ll mp QTOO and 19lOD') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If wafer level is above casing,use"i--
1617 Mail Service Cutler,Raleigh,NC 27699-1617
11.Borehole diameter: i (in.)
,o 24h.For Iniettou Wells: In addition to sending the form to the address in 24a
12.Well construction method: A (c Ae , -- above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc-) l( construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Canter,Raleigh,NC 27699-1636
L3a.Yield(gpm) Method of test i'. �7L 24c.For Water Supply&Iniection Wells: In addition to sending the form to
[� IA /2 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: $ / Amount: 1� G completion of well construction to the county ty health department of the county
t
where constructed.
Form GW-t North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016