GW1-2022-10793_Well Construction - GW1_20221208

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chfis King 14.WATER ZONES
Well Contractor Name OH TO DESCRIPTION
2080-A f l "i 1 i I
ft. fL
NC Well Contractor Certification Number 15.OUTER CASING for mmilti cased wells ORLINER d a livable
Aqua Drill, Inc. FROM To D/IAMETER TTIICKNESS TERTAL
p ft. T ft. 6 t C I y i L
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: FROM I TO DIAMETER I THICICNESS MATERIAL
List all applicable well construction permits#.e.UIC,County,State,Variance,etc.) fL ft. to
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSTZE TmCKNFBS - MATERIAL
:Agricultural []MunicipaUPublic ft fL in.
Geothermal(Heating(Cooling Supply)residential Water Supply(single)
ft. ft, in..
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Itiigution FROM TO MATERIAL EMPLACEMENT METROD&AMOUNT
Non-Water Supply Well: © % ft.
Monitoring _.Recovery ft. , fL
Injection Well: ft. ft.
Aquifer Recharge oGroundwater Remediation
19.SAND/GRAVELPACK da"livable
Aquifer Storage and Recovery OSalinity Barrier FROM To I MATERIAL I EMPLACEMENT METNOA
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft
I-`Geothermal(Closed Loop) Tracer 20.DRILLING LOG'attach additional sheets if necessary)
._ Geothermal eatin Coolin Return Otht� FROM TO DESCRIPTION color,bw4ness,soillrock e, n size,ete
(H g/ g _ (explain under#21 Remarks) ft, ft.
4.Date Well(s)Completed: Dell ID# lI (% % R j v C
5a.Well Location: ft. ft
Al� Pl#zl�� ft
....?ram�_"`. �s�^•:
Facility/Owner Name Facility ID#(if applicable) ft ft F J y Z .
e— ft. ft F
Physical Address,Cittyy,•and Zip ft. f4
21.REMARKS
y •„cd, ,
County Parcel Identification No.(PIN) i'2 C C C�L
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certification: �[
N W 6d'— 42� 0 r
6.Is(are)the well(s) Permanent or OTemporary Si- re of Certified Well Contracfar Date
By signing this form,1 hereby certify that the wrll(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 6res or n- No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 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-I 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: 6©5� 00 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-33@�2000-and 2@a 100) construction to the following:
10.Static water level below top of casing: tY " (ft) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use'-+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
/�j r7C above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: '! 1 L 1 construction to the following.
(Le auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I
13a.Yield(gpm) / Method of test: 51 1' 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submitl one copy of this form within 30 days of
13b.Disinfection type: Amount:,/6 O'Z- 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