GW1-2022-09812_Well Construction - GW1_20221027

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A - C ` 30 l
Et. &
NC Well Canhactor CettificationNumber
15.OUTERCASING for multi-cased wells ORLINER SKa liable
Aqua Drill, Inc. Fttobf To DIAMETER_ THICKNESS MATERIAL
Company Name ft. /=�) ft to in.
�� 16.INNER CUASINp`G OR TUBING(eothermal closed-loon)
ESS
2.Well Construction Permit#:_ (ij J (� FROM To DIAMETER THICKNESS MATERIAL
List all applicable ugll cotstructionpermt s r e -0,, ate,Parfancn_eta) ft ft hL
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN
!...Agricultural FROM TO nmwM vR SLOT Srzi? IMCKNFSS MATERIAL
Municipal/Public f, (L in.
Geothermal(Heating(Ccoag Supply) Besidential Water Supply(single)
ft ft in.
Industrial/Commetcial DResidential Water Supply(shared)
lIrrigation 13.GROU
Non-Water T
FROM TO MATERIAL EA1PLACEMENTMETHOD&AMOUNT
Supply Well: � �
—Monitoring Recovery ft O ft h 1 q ,5
Injection Well:
uerRechar e fi ft
� if g �GroundwaterRemediation
Aquifer Storage and Recovery DSy)inity Barrier .19.SAND/GRAVEL PACK#f a liable '
FROM TO NATERWL EWIACEMENTMETUOD
�_. Aquifer Test �StormwatecDrainage ft ft
Experimental Technology OSubsidence Control ft %
RGeothermal(Closed Loop) 0TraCer - 20.DRILLINGLUG attach additional sheets if necessary),
Geothermal(ffeatirt&Cooling Return) rjother(eVlain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soithock grain sae,etc.)
& ft
� "
4.Date Well(s)Completed: Well ID#k�U�- �'3 ft 5-j— ft
5a.Well Location: s— fL D' B]ue 1 n' 4 L"
ft %
Facility/Owner Name Facility W#(if applicable) ft• &
J7YlL_F ..ta�vt� v q
P�hyyss.ic fal Address;City,and Zip t
+
1L7 t lf'�if�lJC f
2L RRNfARKC
ft •s 9�-i
County Parcel WeatificationNo..(POO O C T 2 0
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one IMougis sufficient) 22.Certification:
N W d.C�
6.Is(are)the:well(s ?ermauent or Temporary Signature o£Cemfied Well Contractor Date
By signing this form,I hereby certify that the uell(s)was(were)constructed in accordance
Z,Is,this a repair to an existing well: E)Yes or�To with 15A NCRC 02C.0100 or 154 NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and erplaln the mature ofthe �Py of this retard has been provided to the well owner.
repair.under t121 remarks section or on the back ofd�ts fosm.
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 OW-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:_ , ��_(ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple rvelfs list all depths ifdlfferent(example-3 Q200'and 2L1a 101)')
construction to the following:
10.Static water level below top of casing:�3 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing rse`+"
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (m•)
24b.For Iniection Wells: In addition to sending the fora to the address in 24a
j above,also submit one copy of this forth within 30 days of completion of well
12.Well construction method: �1
(Le.auger,rotary,cable,direct push,etc.) construction to the following.
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
]3a.Yieid m `
(gP ) Method of test: C !In 24c.For Water Supply&Injection 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: Amount t� completion of well construction to the county bean department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016