GW1-2023-01774_Well Construction - GW1_20230223

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- —WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: �
1.Well Contractor Information: l
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Chris King 14.WATERZOPIES r I
FROM TO DESCRIPTION
Well Contractor Name /�R. Z ft 1�' 1 7
2080-A ft. ft.
NC Well Contractor CertificationNumber 15.OUTER CASING for multi-aced wells OR LINER if a v ticable
Aqua Drill, Inc. FROM TO DL4METER1 1 THICKNESS MATERIAL
ft. ft. � 'n.i D/z2(
Company Name -
! a/ 16.INNER CAMSING ORTQBING ermal closedaoo
2.Well Construction Permit9: '�_o'9'I -0 oo I U FROM TO DIAMTEW, TffiCIINESs MATERIAL
List all applicable well cmtstruction permits(Le.UIC,Couno,.State,Variance,eta) ft ft. I�''
3.Well Use(check well use):
ft ft Iin.
17.SCREEN
Water Supply Well: FROAf TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agdcultival Municipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) idential Water Supply(single) fur ft. in.
lndustrial/Commercial Residential Water Supply(shared) 18.GROUT
'11trigation. FROM I TO MATERIAL. EWLACLMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft' () f.
Monitoring DRecovely ft. ft
Injection Well:
Aquifer Recharge E3GroundwaterRemcdiation ft
_ ft.
19.SAND/GRAVEL PACK d applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL': I niPLACEMENT METHOD
Aquifer Test OStonnwater Drainage ft. ft
I,
Expemnentai Technology OSubsidence Control ft, ft
Geotbermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets N necessary)
FROM TO DESCRIPTION(color,hardness,solihuck rain sim,etc.
lGeothermal(HeatinglCooling Return) Other(e lain under#21 Remarks) 0 � R •� � ,
4.Date Well(s)Completed: Well M# ?� ft- raj ft f
5a.Well Location: t0 J Wez'
ft.
Facility/Owner Name Facility lD#(ifapplicable) % fL 'd e„U.L7—y,V _;
ftFEBPhysical Address,City,and Zip tt. ft
2L REMARKS t ,t,r,:=..•
County Parcel Identification No.(PIN) I: r�"a'©ikSDls
5b.Latitude and longitude in degreesiminutes/seconds,or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certific tioa:
N ev 6 s
6.Is(are)the well(s)aPermanent or OTemporary SlgTdure ofCedified Well[Contrackor 1 ate
By signing this farm,I hereby certify that the wWl(s)was(were)constructed.in accordance
7.Is this a repair to an existing well: 171Yes or e ivith ISA NCAC 01C.0100 or 15ANCAC 02C.0200 Well Construction Siandai ds and that a
If this is a repair,fill out known well courtruction information and explain the nature ofthe copy ofthis 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:
S.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: f SUBWHITAL INSTRUCTIONS
9.Total well depth below land surface: "' (%) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100�
_ construction to the following:
10.Static water level below top of casing: (B-) Division of Water Resources,Information Processing Unit,
lfwater level is above caring use"f" 1617 Matz Service Center,Raleigh,NC 276994617'
11.Borehole diameter: in.
( ) 24b.For Injection Wells: In additionito sending the form to the address in 24a
above,also submit one copy of this f i within 30 days of completion of well
12.Well wnstraetion method: f t 71 construction to the following•.
(Le.auger,votary,cable,direct push,etc.
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ceat er,Raleigh,NC 27699-1636
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13a.Yield(gpm) Method oftest: t 24c.For Water Sminly&Iniection Wells: In.addition to sending the form to
PT Q the address(es) above, also subrnitione copy of this form within 30 days of
13b.Disinfection type: Amount:�l completion of well construction to the county health department of the county
where constructed.
Form aw-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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