GW1--04820_Well Construction - GW1_20240814

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: —
I Print Form
1.Well Contractor Information:/`" /2.1) ////e 11)7 14.WATER ZONES
Well rnn
hector Name FROM TO DESCRIPTION
/, ge G'`it 117S ft' 110 rc FrocAce LA (iPf1
NC Well Contractor Certification Number ft' rt.
Aqua Drill, Inc IS.OUTER CASING(for multi-cased walls)OR LINER(ifs )
FROM TO DIAMETER THICKNESS MATERIAL
Company Name © ft. , SS It 1 C tI"i in, SDQ a1 P' G
9 0 16.INNER CASING OR TUBING(at otllermal cloned-loop)
2.Well Construction Permit#• E.Ft\& P a�o'.-CO e FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.Cottuty,State,Variance,etc) ft. ft, in.
3.Well Use(check well use): h ft, In.
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
MunicipaVPublic ft. ft In.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/Commercial K ft. in.
Residential Water Supply(shared) .�
Irrigation I&GROUT
FROM TO MATERHA,L EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O rt ai ft• 9x 7 i e
Monitoring Recovery ft. Chtf'3 PoVf ' 11�dTat�
Injection Well:
Aquifer Recharge OGroundwater Remediation ft. ft.
Aquifer Storage and Recovery InSalinity Barrier 19.SAND/GRAVEL PACK Of app0eab1e)
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft ft.
Experimental Technology II3Subsidence Control ft. ft
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if meelu y)
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) FROM TO DERCaWrlo t(cater.banks"oe cock We.caste etrs etc.)
4.Date Well(s)Completed:'1'31'a.L-1 Well 1D# i ft. S a SO S toan d jay
►a S" d�octc
5a.Well Location: Sty rt. S S D' B i u e (ran t i e
OwkwsQoj Foime1 o`Eien SS rt' auks ft. Blue &ranite
Facility/Owner Name Facility 11)4(if applicable) ft, ft.
I9`1 14c,i e4 H+'lis Or ReirSvilie ►.)C a13a0 IL ft.
Physical Address,City,and Zip rt. ft. t
ROeKrinSino%en '199Soo61- °-Is li 21.REMARKS
County Parcel Identification No.(PIN) U f a 2D L 4
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilong is sufficient) u I}s,.k
1�O al (b. 3,a net'Lit 31 �,. 22. ticad
6.Is(are)the wells) 1 PerIDaoent or Temporary Signature of Certified Well Con'ores Date
By signi
in accordan
7.Is this a repair to an existing well: ©Yes or '�No vith 15Atg NCAC 02C.0100or ISA NCAC)2C.0200y certify',that the'well(s)Well Consttruct nwar(were) t ructed S orris and that this a form,1
If this Is a repair,fill out known well construction Information and explain the nature of the copy of this record has been provided to the well owner.
repair under#2l remarks section or on the back of thLs form.
23.Site diagram or additional well details:
S.For Genprohe/DPT or Cloud-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 OW-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: `e. .Li
For multiple wells list all depths rfdijjerent(example-.t 200'and 2@100) (R') 24a. For All Wells: Submit this Slml within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: 50
If water level is above casing,use"+" (B) Division of Water Resources,Information Processing Unit,
6 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: �a-)
24b.For Injection Wells: In addition so sending the form to the address in 24a
12.Weil construction method: Roioxl Kir above,also submit one copy of this Form within 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc.) construction to the following:
. FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground ground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 4 Method of test: Catch ST reNE 24c.For Water Supply&Injection Wells: In addition to sending the form to
bltH ��•,t'o the address(es) above, also submit OM: copy of this form within 30 days of
13b.Disinfection type: Amount: «®'Z completion of well construction to the countyhealth de
pdepartment of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22_2016