GW1-2022-09004_Well Construction - GW1_20220923

WELL CONSTRUCTION RECORD GW-1 Print Form
For Use Intemat Only: -
L Well Contractor Information:
Chris King
Well Contractor Name ZONES 14.WATER I fv.n�„��..� .A� .. ...•_..,c.0" FROM 2080-A S t P � � 2022 �` TO DESCRIPTION
ft
NC WeII Cantcacl-CertitioationNumber ft• ft
Aqua Drill, Inc. (Jr.,, 15.OUTER CASING-tr.,m w—edwells OR LINER ifs Usable
CIG FROM TO DIAMETER I T1 5:lQ, ESS MA /'
Company Name ft `f74 T6RiAL
2 ft S�tzZi j I/)C�
2.Well Construction Permit#: •G.�f Q.22 O J 6 16•INNER CASING OR TUBING comermal closed-ioo
List all applicable well construction 0 FROM TO DIAMETER THICKNlwSS
P�+Its r e.U1C,Cover ;Statz I`ariartce,eta) ft ft in. MATERIAL
3.Well Use(check well use): In ft ft
Water Supply Nell: 17.SCREEN
Agricultural MATF.R(AL
FROM TO nIAMErE SLOTSIZE
R TRT
�. MunicigaUPublic � in.' cKNF.ss
Geothermal(Heating/Cooling Supply) idential Water Supply
PPI y(single) ft.ft. ft
evidential Water Supply(shared)
w.
Irri lion PP y( and) I&GROUT
Non-Water Supply Well: FROM TO MATERIAL Monitoring ft ft Et<1PLACEMENTMEiHOD&AMOUNT
Recovery
Injection Well: ft. (b
Aquifer Recharge i13Groundwater Remedwion ft
Aquifer Storage and Recovery DSalinity Barrier 19.SAND/GRAVEL PACK da lieable
MATERIAL IL Fd4IPLACEMENT METHOD
Aquifer Test FROM TO
3Stormwater Drainage fL
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer ft a ft
Geothermal 20.DRILLING LOG ttach additional sheet,if access
(Heatir /Caoli Retum) Other(ex lain under#21 Remarks) FRO"' To DESCRIPTIUN(color 6ardaeq soiUrnck a eta
4.Date Well(s) ft ed(s)Completed:`l �l:�r�WeIl ID#
5a.Well Location: ­n' ft. 35 "
35- ft 4-12
ft ft
Facility/Owner Name T—
Facilitylp#(ifapplicable) ft. {t
�►t_r�__1Zc�
Physical Address,City,and Zip ft ft
/ ft ft
ZL REMARKS
County
Parcel Idescation No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decim(if=U field,one lat/lcog is suffrciem) al degrees;
22.Cerod Ilion:
,,,,,,,,,,JJ � a 1
6.Ware)the well(s)�Ilitermanent or Temporary Sigaatrue ofCertifi Well Contractor
PP'-'- �� ate
dance
7.is this a repair to an existing veep: yes or tY.tF,T0 By signing this form,1 here _
Ijthis it a repair,fill out brown well With
construction information and eplain the nature ojthe Py afthic record h 0been pra 100 Or ed to h ewe 1 n0 JVa
r Constnrction Standardsair t a
repair under#21 rrmarla•section or on the back ofthisform.
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having file same 23•Site diagram
me back of this wen details:
construction,only 1 GW-i is needed Indicate TOTAL Iron may page to provide additional well site details or well
drilled. NUMBER of wells construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface:_ Z SUBMI�'TAI STRUCTIONS
Formula'plewellslinoUdepthsfdff,,t(emnple_ a�00'andl(a)1005 (fi) 249.For AII�yepg; Submit this fwithin30 days of completion of well
10.Static water level below top of casing:
construction to the following:
Ifrmterlevel is above casing.use 1".. / 00 Division of Water Resources,Information Processing Unit,
IL Borehole diameter. 1617 Map Service Center;Raleigh,NC 27699-1617
Cam) 24b.P�>L For Infection Weps: In ad
12.Well construction methods dition to sending the form to the address in 24a
ti ) iZ t�t7 r" above,also submit one copy of this form within 30 days of campletion of well
e auge,rotary,cable di„ect etc. ---r-- construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Under
ground Injection Control Program,
1636 Mai!Service Center,,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test �-
24c.For Water SuDDIv&Infection Weps:
.� the addresses) above, also submit one c In addition to sending the form to
13b Disinfection type: Amount =sL copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Dcpartment of Environmental Quality-Division of Water Resources
Revised 2-22_2016