GW1-2022-09815_Well Construction - GW1_20221027

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use only: --
1.Well Contractor Information:
Chris Ong 14.WATER ZONES
Well Contractor Name FROM TO DESCRnrIION
2080-A ft' .3 e 1 in
fL fL
NC Well Contmetor Certification Number
IS.OUTER CASING for multi-cased wells OR LINER if a licable
Aqua Drill, Inc. Faon1 To DIAMETER TlHctcrQtess MATERIAL
CompauyNamc ft. ft �5�� in t p� /j� v
/ �i 16.INNER CA ING OR TUBING eathermal eiosed-loo Cs
2.Well Construction Permit#:7!�_c�L)�)lr'I U( 1�. FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ue11 coustructionpermits(Le.fIl,Crum[};State Variance,etc.) ft. ft. ln.
3.Well Use(check well use): fL ft. In.
Water Supply WeA 17.SCREEN
Agricultural [)Municipal/Public aUPnbllC FROM TO WAMEFER SLOTSIZE THICKNESS MATERIAL
_ P ft ft is
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft ft.
IndustriaUCornmercial Residential Water Supply(shared)
IS.GROUT
Irri ation FROM TO I4fATERiAI. EMPLACEMENTMETROD&AMOUNT
Non-Water Supply Well: 0 t• ? � t: tU 1 l^� 5'•
Monitoring Recovery ft. ft
Injection Well:
Aquifer Recharge DGroundwater Remediation (L fL
Aquifer Storage and Recovery DSaliaity Barrier IR SANDlGRAVEL PACK tf a livable
F'R011f TO DATERIAL EMPLACEMENTMETHOD
Aquifer Test E]StotmwateTDrainage 1L ft.
Experimental Technology DSubsidence Control fL
Geothermal(Closed Loop) OTracer 20.DRIL G LOG(attach additional sheets if necessa
Geothermal(Heating/Cooling Return) - Other(explainunder#21 Remarks) FROM TQ DESCRIP7IU color,hardness,sollt nck�� rain sire etc.)
n � � fLy Not.k4�nrid-
'
4.Date Well(s)CompletedJ-2 Well ID# ft. t 3C,� - Mud
Sa.Well Location: r - 1 ft 3•Cl )'l1 i 7-C'.
% fL
Facility/Owner Name I Facility ID#(ifapplicable) R• fL
fL ft QL_ �_p f .
Physical Address,City,and Zip r tt• fL
fi1 A 2L RRMARKI'
COan ?steel ldentificaflon No.(PIN) r 3lE`,Sl 1 rCC :ilr�/L)r,4
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(iftvell8eld,one lat/longis sufficient) 22.Cerlificatio
N W ..
d =
6.Is(are)the weil(s) Permanent or OTemporaty StgnatareofCerttSedWellContra Date
By signing this form,I hereby certify that the srell(s)was(were)constructed in accordance
7.Is this a repair to an eristing well: []Yes or/KNo with 15A NCAC 02C:0100.or 15A NCAC 02C.0200 Tfrdl Construction Standards and that a
Ifthis is a repair,Jill outfinown trell construction infortnation and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair tinder#21 remarla section or on the back ofthisfonn.
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 ofwells Construction details.You may also attach additional pages if necessary.
drilled;
SUBAUTTAL INSTRUCTIONS
9.Total well depth below land surface: O Form 24a.For Ali Wells: Submit this form within 30 days multiple all ifdifjerem 1(erampJ3Q200'andlta�1003 of completion of well
construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources
Ifivater levelis above casing,use"+'• � ,Information Processing Quit,
1617 Mail Service Center,Rald9b,NC 27699-1617
11.Borehole diameter_ fin,)
/ J 24b.For Iniecdon Wells: In addition to sending the form to the address in 24a
12.Well construction method /q;Jz G i �f above,also submit one copy of this form within 30 days of completion of well
(Lr-auger,rotary,cable,daectpush,etc.) construction to the following.
'FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
13a.Yield(gpm) 131636 Mail Service Center,Raleigh,NC 27699-1636
Method of test: � bC 24c.For Water Supply&Injection Wells: In addition to sending the forth to
41-11— the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount C9 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