GW1-2023-00883_Well Construction - GW1_20230118

R .j / .� Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: A 1t' /�
1.Well Contractor Information: JA N 18 2023
Chris King • : i
14,WATER ZONES. 1�4u, : r,:•,�;;.,
Well Contractor Name FROM TO DESC
2080-A 6 5 fr. OY ft. '
rr. rc
NC Well Contractor Certification Number
.A5:.OUTER CASING fur multi-cased:wells:OR LINER tf a Iicable
Aqua Drill, Inc. FROM To DIAMETER Talcxiv.7Es'
n4ATE,Rt/AL�t
CompanyNamc ft. �Cj 3n.Ka
16.INNER CASING OR.TUBING. cothermal closed-loo
2.Well Construction Permit#: ;J,-- FRo11t To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) Ill. fr. in.
3.Well Use(check well use): ft & in.
Water Supply Well: 17.SCREEN
FROM TO I DIAMETER I SLOTSIZE ITAICKN'ESSI MATERIAL
HAgricultural Municipal/Public ft, fL u,
Geothermal(Heating/Cooling Supply)residential Water Supply(single) ft. % in.
Industrial/Commercial E3Residential Water Supply(shared) 18,GROUT'
- hriRation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft ;20 ft' 06e Avi
Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge rIGroundwater Remediation
Aquifer Storage and Rix Query Salini Barrier .19.SAND/GRAVEL PACK if a licable
ty FROM TO MATERIAL EMPLACEMENT METHOD
_.Aquifer Test oStormwater Drainage ft ft
Experimental Technology DSubsidence Control fL ft.
Geothermal(Closed Loop) DTracer 10.DRILLING LOG attach additional sheets ff necessary)
Geothermal(Heating(CoolingRetorn) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,sallfrock e, 'n size,etc.
j ft. � ft. V-
4,Date Well(s)Completed:l Well ID# ft. j Sl� G j CSC r
5a.Well Location: 20 ff 2
ft. A.
Facility/Owner Name Facility ID#(ifappfieable) ft. ft.
9 7.5-C1 N(� C"7 ft. ft
Ph ical Address,City,and Zip ft. ft
'0 KJ `.21:REMARK&,.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(jfwell field,one lattlong is sufficient) 22.Certification:
�� !q
N W �" 3 i�K/1• � L�
6.Is(are)the well(,VdPermanent or Temporary Signature of rtified well Con r Date
By signing this form,I hereby certify that the walls)wus(were)constructed in accordance
7.Is this a repair to an existing well: EJYes orTo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and drat a
If this is a repair,fill out/mown 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Iotal well depth below land surface: (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For inuldple wells list all depths if different(example-3@2200'and 2@100� construction to the following:
10.Static water level below top of casing: (' (ft) Division of Water Resources,Information Processing Unit,
(water level is above casing use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
;7,� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: i 1 � 'ul construction to the following:
0-c-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
13a.Yield(gpm) Method of test: 15 24c.For Water Supply&Iniection Wells: In addition to sending the form to
L� ,T 6 the address(es) above, also submit.one copy of this form within 30 days of
(] I
13b.Disinfection type: Amount:( completion of well construction to the county health.department of the county
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016