GW1-2022-06717_Well Construction - GW1_20220711

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only.
1.Well Contractor Information:
Chris Kin 14.VPATEIl zoI S i
g FROM TO DESCRIP•RON I
Well Contractor Name —ft. ft 5 L;J
2080-A Q R• 'Jo '71
NCWeUContmetorCertificationNumber 15.OUTER CASING for multi-casedRells ORLINER tfa livable
FRoai To DLnMETER 'rH[cKN s MArE
Aqua Drill, Inc. rr fr. $ yq
CompanyName 16.INNER CASIDiGORTDBING eothermalclosed-too
C.
R.
FROM TO DIAMETER • TIUCKNESS MATERIAL
2.Well Construction Permit#:
List all applicable well construction permits�.e.U1C,Comtr Stat4 Var(one4 etc.)
R. ft: in.
3.Well Use(checkwell use):
17.SCREEN
Water Supply Welh FR011f TO DIAMETER SLOT SIZE3Agri THICKNESS MATERIAL
cultural DMunicipat/Public R. R. in.
_Geothermal(Heating(Cooling Supply)residential Water Supply(single) R R- in.
Industrial/Commercial E311esidential Water Supply(shared) 18.GROUT -
FROM TO MATERIAL__ t E67PLACEMF.NT/AiETROD&AMOUNT
lrri ation ft R- �(T Z J 46
Non-Water Supply Well: 6
Monitoring Recovery R ft'
Injection Well: R. ft.
Aquifer Recharge oGroundwaterRemediation 19.SAND/GRAVELPACK da livable
- Aquifer Storage and Recovery salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer'Test oStomrwaterDrainage % ft
_Experimental Technology EISubsidence Control ft
Geothermal(Closed Loop) Tracer 20-DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color ha+dac5s,soiU+ock e, siu,etel
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks tit ft. ft, 7 6
4.Date Well(s)Completed:4?'t!� Well ID# r'd IZ ,C/- - ,n J
R. ft
So.Well Location:
ft. ft
Facility 1Dtl tf livable R. (t
Facility/OamerName t3' ( aPp � -
ft R- � � ��
t R. ft
Physical Addtess,City, ndZi
21.REMARKS I _ ''
County Parcel Identification No.(PIN) M-a i0lC
A ►d z��sv`ra z're'.IG M
5b.Latitude and longitude in degrces/minutes/seconds or decimal-degrees: �• W "'
(if weU field.one latllong is sufficient) 22.Certificati n:
SignatnreofCertifiedWe Coatacori Date
6.Is(are)the well(. ermanent or Temporary
By signing this form,I hereby certify that the w.ff(,)oat(were)constructed in accordance
7.Is this a repair to an existing well: fD. Yes or�To with 15A NCAC 02C.0100 or 15A NCAC 02C.0260 We Conatn+ction Standards and that a
copy afthis record has been provided to the well owner.
lfthts is a repair,f ll out known well construction information and explain the nature of the
repair wider 921 remarkrsection or on the back ofthisform. 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 details.You may alo attach addition)pagesifnecessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of w s
ells
drilled—�j SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: t� 00 24a.For AU Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdperent(example-3@200'and 2@100) construction to the following
10.Static water level below top of casing: 30 (fL) Division of Water Resources,Information Processing Unit,
Ifivater level is above casing,use+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in) 24b.For Infection Wells: In aldditioa to sending the form to the address in 24a
above,also submit one copy,this form within 30 days of completion of well
12.Well construction method: Z )7 construction to the following:
(Le.auger,rotary,cable,dinxtpush,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service i enter,Raleigh,NC 276991636
13a.Yield(gpm) l Method of test: I �� 24t:For Water Supply&Iniecion Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type:
i _ Amo>mt: completion of well construction to the county health department of the county
� �'
where constructed.
Form GW-1 North CarormaDepartment of Environmental Quality-Division of WatcrResources Revised 2-22-2016