GW1-2022-08899_Well Construction - GW1_20220912

WELL CONSTRUCTION RECORD GW-1 Print Form
For lntemal Use Onty:
1-Well Contractor Information:
Chris King
14.WATER ZONES
wen ConnaMotName 2080-A FROM TO
DESCRlpTION
�• G� � G t �, M,
NC WellConhsetorCertificatianNumber ft ft•
Aqua Drill, Inc. 15.OUTER CASING formultiraseId ORLINER ifa licabie)
FROM TO DIAMETER THICKNESS MAT&RIAL
Company Name ® ft. rt 5i7/Z 2\
16.INNERCASINGORTUB[NG eothermatdosed-loo lal ✓'C
2 Well Construction Permit#: 26 "0000 Z 7
List all applicable 14WI construction FROM TO DIAMETER THICKNESS pfATERW L
permfts(ce.rIIC•C 43'State.Variant;eta) k in.
3.Well Use(check wen use): �
tt. in.
Water Supply Well: 17.S CREEN
Agricultural Mmnicipaveabtic FROM TO DIAMETER -SLOTS[ZE rRICKNESS MATERIAL
Geothermal fL ft io(Heatiag/Coo]ing Supply) Residential Water Supply(single)
Industrial(Commetciai ft• ft
Residential Water Supply(shared)
irri tion 18.GROUT
NOR-Water Supply Well: FROM TO MATERTAr. EMPLACEMHNT METHOD&AMOUNT
Monitoring � (3 ft.
�,lti .. G S
Injection Well; --Recovery ft. ft.
Aquifer Recharge DGroandwater Remediation ft ft.
Aquifer Storage and Recovery Salinity Barrier FROM To
PACK d a Unable
o
Aquifer Test To MATERIAL, EMPLACEMENT METHOD
E)StormwaterDrainage ft; IFIL
Experimental Technology 0subsidence Control
ft f1t.
Geothermal(Closed Loop) Tracer
Geothermal 20.DRILLING LOG attach additional sheets if necessa
(Heatigg/Cooling Return Other(explain under#21 Remarks) FROat TO yDESCRrPTTON(color 6ardaess,sofurwk rya IQ 4 size
(} ft- IZ C C
4.Date Wells)Completed•�_ '?�`Z Z Rrel!iDl/
3 >z
Sa.Well Location: 5�W C OC lL.
1
2 ft. yz5-ft. 13 1
Facility/Owner Name ft.
Facility tD#(if applicable) R
iL8
Y�1 t C ft. �. .
phYslnal,�Adyd(re�ss,City,and Zap �?�f' ,
KJQ01-Y J '1 ft ft
n -
County 2L REMARKS F r `�
Parcel Identification No.(PIN) Pr
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
J Ye
(ifwetl field,one Wong is sufficient) y
22..rt—ofce,&dW�.11C..tc���
Certification:
6.Is(are)the wells ermaneat or
Temporary Sig
Date
7.I1 this a repair to kn existing well: E]Yes orLM BY s+V'ng d Is farm,t hereby certh,that the is�ell(s)war(were)constructed in accordance
rethis is a repair,ren out known well on the back
thi j n. and ezplatn the nature ojthe copy of�record has been0100 r 15Aed to the well owner.ell Construction Standards and that a
repair under#21 remarks section or On the back ojthls form.
23-Site diagram or additional
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You Way use the back of this well details:
construction,only 1 OW-1 is needed Indicate TOTAL NUMBER of wells Page to provide additional well site details or well
drilled: construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: - SUBMITTAL INSTRUCTIONS
For Multiple Wells list an depths lJdifferem(erample 3Q200 and2@lpp (N 24a For trt vi
AQ Wells: Submit this fori
f 3 construction to the following
if that 30 days of completion of well
10.Static water level below top of casing: co
water level is above casing use +f (ft•) Division of Water Resources,Information Processing Unit,
11.Borehole diameter. 1617 Mail Service Center,Raleigh,NC 27699-1617
{in.)
12.Well construction method: fr?
24b.For Inie�cNon Welk: In addition to sending the form to the address in 24a
) Iz s 1 above,also submit one co of this form wi
(Le-auger,rotary.cable,direct push. construction to the following thin 30 days of completion of well
EWATERPPLY WFrr c ONLY: Division of Water Resources,Under
ground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test fi 24c ater Su I &bjea6on�Welis: In addition to sending the form to
ype; Amount: Q the address(es) above, also submit one'copy Of this form within 30 days of
completion of well co
nstruction to the
where constructed. county health department of the county
Form GW-1 North Carolina D epartment of Em"roomental Quality-Division of Water Resources
Revised 2-22-2016