GW1-2022-09814_Well Construction - GW1_20221027

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WELL CONSTRUCTION RECORD(GW I) For Internal Use Only_
1.Well Contractor Information:
Chris King
14.WATER ZONES
Well Contractor Name FROM To DESCRIPTION
NC Well Contractor CertificationNumber 5—5'% Jr,1," ft .20 K 1 P,(ii
IS.OUTER CASING for mulfi-cased wells OR LINER if a licahle
Aqua Drill, Inc. Mom To DL4KETERr I THICKNESS MATERLAL
CompanyName ft- ft y i� in• 9V CS 1 k
��_ S / 16.1NNERCASINGORTUBING eothermaldosed4no
2.Well Construction Permit#: J C� V fY/� FROM TO I I)LAMTERT THICKNESS I MATERIAL
List all applicable Hell construction permits(ie.UIG,Count};State Variance etc.) it ft I in.
3.Well Use(check well use): ft: tt in.
Water Supply Well: 17.SCREEN
i. FROM TO DIAMETER SLOTSiZE THICIQv'[i43 MATERIAL
Agricultural unicipal/Pub[ic f. It in.
Geothermal(Heating/Cooling Supply)fResidential
sidential Water Supply(single) e. —ft. ;a.
-:Industrial/Commercial Water Supply(shared)
IB..GROUT
IIri lion FROAf To MATERTAI. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Welb ft G� ft
Monitoring Recov
�Y ft fti
Injection Well:
Aquifer Rech e ft ffi
� �Gmumdwater Remediation
Aquifer Storage and Recovery OS Bye.
y 19•SANDIGRAVEL gn rf a licable
^. omrwaterDra FROM TO MATERIAL EMPLACEMENT METHOD
AgniferTest DStorm inage � ft
Experimental Technology OSubsidence Control & ft
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if.neceessa
Geothermal(Heating/Cooling Return) ;-Other(explain under#21 Remarks FROM TO DESCRIPTION(color,hardness-GIVrock rain size,ete
ft ft Lt
11-4 4' : ft!.DateWell(s)Completed1f� '� v.uW#� f0 ft- cc,
5a.Well Location: SV k GS- % I?I vc
ft. ft. i
Faaccil/ity/OwnerpNaQme .p Facility lD#(Napplicaablle)! ft. ft.
jJ�•�"�f-�O r �r�z t�Y /' f.��u(YVa ft ft
Physical Address,City,and Zi �— ft. ft
AA rM Vic'-e 2L REN ARKS 7 .2077
Cow Parcel Identification No.(PIN)
5b.Latitude and longitude in d Ii1ty' 16:1Cs1 I' tvr ;r
gr egrees/minutes/seconds or decimal degrees: e
(ifwell field,one lat/long is sufficient) 22.C do
L
N
c�
6.Is(are)the well(sN-iyt'+ermanent or Temporary sigoatmeoMeitifie-Well Contractor Dal
v— By signing this form,I hereby certify that the Iell(s)was(were)constructed in accordance
7.Is this a repair to an existing weU; Yes or No with I5A NCAC 02C.o100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out knorlm well construction infonnatt n anmd—explain the nature ojthe copy ofthis record has been provided to the wall owner.
repair under#217emarks section or on the back oftlus form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same Yon may use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed Indicate TOTAL NUMBER ofwells construction details You may also attach additional pages if necessary.
drilled:
�/� SUBNNITAL INSTRUCTIONS
9.Total well depth below land surface:_Lt52 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(a3200'and 2Qa 1005
construction to the following:
10.Static water level below top of casing:�G4 (it.) Division of Water Resources,Information Processing Unit,
"+'
ljwater level is above casing,use 1617 Mall Service Center,Raleigh,NC 2 769 9-1 617
1L Borehole diameter: n (m,)
i 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: /�Z 1J1717 l above,also submit one copy of this form within 30 days of completion of well
(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
13a.Yield(gpm) , Method of test:S. 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
13b.Disinfection type. Amopnt, completion of well construction to the county health department of the county
where constructed
FormGW-1 North Carolina Department ofEnvironntental Quali
ty ty-Division of Water Resources Revised 2-22-2016