GW1-2022-06597_Well Construction - GW1_20220711

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King :14.WATETUONEs
.FROM TO DESCRD:IIONI
Well Contractor Name !7 c�-D 2/ ft 3 Q !
2080-A .�ft. tr R. Ci 3
i
NC Well Contractor Certification Number 15.OUTEXCASING for inultirased wells UR-LINER if a livable.
Aqua Drill, inc. FROM TO DL4 11 THICKNESS MATERIAL
Company Name
�C/�^ �� 16.FRINNERCASINGOR.TUBIAM eotfiermalcloCINEo
2.Well Construction Permit#gym �„ fiv FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.Stag!Variance•etc.) R ft !;in.
3.Well Use(check well use): R ft {In
17:SCREEN-
Water =. :'•°'
Bupply Well: FROM TO DIAMETER ,SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft M '
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) R g• in,
IndustdaUCommercial [3Residential Water Supply(shared) ,1S.:GROUT•..i 1
hil ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: - ft. 0 ft. tz0 C '
Monitoring Recovery ft: ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SANDIGRAVELPACICifa' llcatile
Aquifer Storage and Recovery [3Salinity Barrier FROM TO AIATERUL.L EMPLACEMENT METHOD
Aquifer Test StormwaterDrainage ft. M
:)Experimental Technology Subsidence Control ft R
-i Geothermal(Closed Loop) Tracer 20:DRILLING LOG:(attach additional stieets if riecess t. =
FROM TO DESCRIPTION eolor,hardnes sol0rock raiasize,etc.)
Geothermal(Heating(Cooling Return) [ Other(explain under 421 Remarks)
M ft
4.Date Well(s).Completed6 We11ID#(0`t 310 ft. ft go&&
5a.Well Location: ft
ft ft.
Facility/Owner Name Facility ID#(if applicable) ft ft
ft [t rA
l J G;� i�� .i�Q �'1� 8�F����4 e 1.��Vy Ct 17�1�, ' „•,
Physical Address,City, d Zip ft ft � 112029
1R-'1 h�l r e zf nEMARxs
County Parcel identification No.(PIN) T .iftiVv�t7�9!j�!1\fT
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: vat TS V
(ifwell field,one lat/longis sufficient) 22.Certidicatio '
,12
N W N
6.Is(are)the well(s)O.Ik—anent or 'OTemporary SignatumofCertifiedWeUCoiftractor Date
e�2 By signing this form,I hereby certi&that the weU(s)was(were)constructed in accordance
7.Is this a repair to an existing well: nYes or. ,[40 with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that
If this is a repair,'fill out known well construction information aan•-d Aplaiu the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on 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 wcll 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: 7 �j (f) 24a. For All Wells: Submit thg!form within 30 days of completion of well
For multiple wells list all depths ifdifferent.(ewmple-3 a200'and 2 r@100) constiuction to the following
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing.use"+ 1611 Mail Service tenter,Raleigh,NC 27699-1617
11.Borehole diameter: f n) 24b.For Injection Wells: In addition to sending the form to the address in 24a
,Z I s 1 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: /4 I constmcti.to the following.
(Le.auger,rotary,cable,direct push,eta) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) v Method of test 24c For Water Sup
DIy&Iniection Wells: In addition to sending the form to
q the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection type: Hrr Amount: l Q Z-, completion of well construction to the county health department of the county
where constructed. li
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016