GW1-2022-07989_Well Construction - GW1_20220830

Pr'inf Form`
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King MMATER ZONES-
FROM TO DESCRIPTION
Well Contractor Name �Q fC ft. 12
2080-A 3 6-/ / . 1
,
NC Well Contractor Certification Number '15.OUTER CASING ci-multi-cased;w"rills OR'-LINER-ith livable
Aqua Drill, Inc. FROM To D/tnrvie.rFR TmcxivFsys MarEAlunL
Company Name 16.INNER CASING.URTUBING(eothermalclosedLIoo _.= ,
2.Well Construction Permit# � �. ' 1✓t�/�/" FROM TO DIAMETER THICKNESShATERIAL
List all applicable well construction pits.l UIG Cota+[y,Slate,Iranance,etc J D in.
3.Well Use(check well use): ft.
L f
M'SCREEN,.
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
Agricultural []Municipal/Public ft, fL
Geothermal(Heating/Cooling Supply) ff;.$esidential Water Supply(Single) ft. ft, in.
-_lndustrial/Commereial ollesidential Water Supply(shared) 18..GROUT.:
M Irrl atien FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft Q it �c Z . C L
Monitoring f-Recovery R- D•
Injection Well: ft. f.
Aquifer Recharge FIGroundwater Remediation
:19.SANDIGRAVELPACK(if a ]icable':-
Aquifer Storage and Recovery Salinity Battier FROM TO nATERIAL 'ESIPI.ACEMENT METHOD
Aquifer Test DStolmvlatcrDrainage n' fL
Experimental Technology OSubsidcnce Control ft ft.
Geothennal(Closed Loop) OTracer ',20.DRILLING LOG(attach'additional`stieets'itnec@ss
roft.
TO DESCRII;'[ION color,hardness,soiVtacic rain size,etc)
Geothermal(Heating(Cooling Return) __Other(explain under#21 Remarks) ft
d.Date.Weu(s)Completed Well ID#�-©a- fr. .� J _ Mud
5a.Well Location: 3bS I � u c L,z. Ar,._,e
ft w rL.•'`�tl 9
Facility/Owner Name Facility 1D#(if applicable) D•
J 3LJ ke,� kit � �_---'--� ft. AU r
(l�1�u>n � �� d17L� 19 r[,`111�
Physical Address,City,and Zi�
21t REMARKS•-:. . ^if,'"q.; r�
19111m,11ma.& D%,VQ/30G
Cauuty Parcel Identification No.OW
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22`C/errttifiication:
N W I/ ,1��/J r A-�� / -d 2,
n 6
6.Is(are)the well(s) rmanent or Temporary +gnature of Certified Wll Contrd or Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes onto with 15A'NCAC 02C.0100 or 15A NCAC 02C•0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the rtalure of the copy ojthis 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 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 ifnecessary.
drilled: ? SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: - 0 l M-) 24a:For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 200'and 2@100) construction to the following:
10.Static water level below top of rasing: ---> -9 (fL) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
/I /• / above,also submit one copy of this form within 30 days of completion of well
n
IL Well construction method:� /z/�11 construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: JL i 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: /1 �- completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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