GW1--03415_Well Construction - GW1_20230515

i
WELL CONSTRUCTION RECORD(GW 1) Print Form
For Internal Useonly:
I.Well Contractor Information:
Chris King
14.WATER ZONES
Wcll Contractor Name FROM TO DESCRIPTION
2080-A ft
I
NC Well Contractor CettificarionNumber ft, ft.
Aqua Drill, Inc. IS.OUTER CASING(for multi-medwetls)OR LINER Lfa licable
FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft S—Q it. S�� in. / �y �6
-4 !/ l y�f M L _ 16.INNERCASINGORTUBING eothermalclosed-loo 2.Well Construction Permit#:` T�cY 1,a FROM To DIAMETER TIIICKNEss rATERIAL
List all applicable hell construction pern its(l e.UIG Count);State irariaxce,era) ft. ft in,
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN
Agricultural i ROAi TO DIAMETER SLOT SIZE THTCKNESS MATERTAL
[( Mtmicipal/Public ft. ft in.
Geothermal(FIeatingJCooling Supply) t'� Residential Water Supply(single)
Industrial/Commercial fL
oResidentiai Water Supply(shared) 111.GROUT
Irti lion
• FROAL TO MATEItfAl. EAfPLACEMFIVI'AfETHOD&AMOUri7 Non-Water Supply Well: � � � c S
Monitoring F ' lift
Recovery ft. ft
Injection Well:
Aquifer Recharge DGroundwater Remediation ft. ft
Aquifer Storage and Recovery oSalinity Barrier 19.SANDIGRAVEL PACK ifa licable
FROAL TO MATERIAL EMPLACEMEdTMETHOD Aquifer Test E3StonTtwaterDrainage ft ft
Experimental Technology Subsidence Control f. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(e lain under#21 Remazks) AI To DESCRrPTION(color hardness solVmek a rnna sizes era
ti L .
4.Date Well(s)Completed: - _�3 Well lD# ft. y--' ft
Sa.Well Location: ft $ ft 3CvG /z ,
uilc
Facility/0wnerName Facility ID#(ifapplicable) ft, ft �j�,w,,•
�� ' � r9r'`r'f2 ��12 ��•�fZL .�1�.1C`a�t'l11 �,� IL ft 1 Physical Address,City,and Zip 't 5
�y ft. ft I
21.REMARKS .nrupSx:r
County Parcel Identification No.(PIN) r.f fr tr•� QL�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latliong is sufficient)
22.Ce�.d
N We
6.Is(are)the wells) rmauent or Temporary rachac[ Date s
y signing 1hisfonn,I hereby
accordance
7.Is this it repair to an existing well: oYes or�No i th ISA NCAC 02C 0I00 r SA NCAC 02C.0100 Well Constructions ructed Standatrds and that a
Ifthis Fs a repair,fill out/-town well construction lr formation and erplain the nature ofthe copy ofthis record has been provided to the well owner.
repair under 921 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-i is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: � (�)
Formultfple'veils list all depths ifdiBe construction
For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: -70
If'vaterlevel is above casing,use +^ (fh) Division of Water Resources,Information Processing Unit,
11.Borehole diameter:
1617 Mail Service Center,Raleigh,NC 27699-1617
(in.)
246.For Infection Wells: In addition to sending the form to the address in 24a
12.Well constructioi)method:_ /y 6-n Q'lZ t I above,also submit one copy of this form within 30 days of completion of well
(Le,auger,rotary,cable,dimet push,e 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 b 1,A- 24c.For Water Su. I &Infection Wells: In addition to sending the form to
13b.Disinfection)pe- Amount the address(es) above, also submit one copy of this form within 30 days of
f� ®-�-- 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