GW1--04631_Well Construction - GW1_20240809

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only: — Print Form
I.Well Contractor Information:
Well r ("iii- A////�/) 14.WATER ZONES
'irraetor Name FROM TO DESCEIPrON�3f 3fe ft. 4► -
,-�qe i
R.
NC Well Contractor Certification Number ft.
Aqua Drill, Inc IS.OUTER CASING(for multi-cased wells)OR LINER(if apQ• le)
FROM 1 TO I DIAMETEF I THICKNESS 1 MATERIAL
Company Name ft• ft. in.
16.INNER CASING OR TUBING(geothermal cloud-loop)
2.Well Construction Permit#: FROM TO DIAMETER: THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
°AgriCUltlrral FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
�Municipal/Publie ft. iL in.
°Geothermal(Heating/Cooling Supply) Residential Water Supply(single) _
ft ft 1O
1ndustrial/Commercia(
Residential Water Supply(shared) IS.GROUT
"Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
°Monitoring °Recovery ft. R.
Injection Well:
R.Aquifer RechargeGroundwater Remediation ft.
quifer Storage and Recovery Barrier 19.SAND/GRAVEL PACK(if appttcabl�
FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test DIStormwater Drainage ft. ft.
Experimental Technology ICSubsidence Control ft. ft
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additinaal tthhs:ta if necessary)
Geothermal(Heating/Cooling Return) f Other(explain under#21 Remarks) FROM .Tiro
utisc ON(w1or,harmsti oowroek tYar ttaln etre ate
/lift.
4.Date Well(s)Completed: Well DUft. /w fo
ft. ft. 1.—.`Sa.Well Location: f
ft. ft. t - :/ t.
Facility/Owner Nance Facility ID#(if applicable) ft. ft.
!- �
Physj Address,City,and Zip ft. ft.
t5 ,"/�e-$ 21.REMARKS t;t.:.,,
County Parcel Identification No.(PIN) a,' f e.d,ere r
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �!/
(if well field,one tat/long is sufficient)
t 22, cation:„ -------,, e_4'
6.Is(are)the well(s)OPermanent or fir emporary Signs of Certified Well Contractor Date
By signing this Jorei,1 hereby ceritif},that he well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 1]Yes or [JNo with ISA NCAC 02C.0100 or ISA NCAC t 2C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction reformatin,,and explain the nature of the copy of this record has been provided to 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 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 attack additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �� (ft) 24a. For All Welts: Submit this t¢rri within 30 days of completion of well
For multiple wells list all depths#'different(example-3 00'and 2( 0)
construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater Tavel is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1 % (in,)
24b.For Injection Wells: in addition to sending the form to the address in 24a
12.Well construction method: A / A"`" ,,/(o above,also submit one copy of this:ben within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,eta.) construction to the following:
FOR WATER SUPPLY WEL S ONLY: f Division of Water Resources,Underground Injection Control Program,
/ 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) L Method of test:f ' 24c.For Water Supply&Injection Wells: In addition to sending the form to
a p the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection
type: J 7� AAmount:. L completion of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina Dcpaetment of Environmental Quality-Division of Water Resources Revised 2-22-2016