GW1--03596_Well Construction - GW1_20230522

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATERZONES 1
Well Contractor Name FROM TO DESCRIPTION
2080-A l°18 ft. )G f ft. /5 6111/7t ini
- ft. ft. ' I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
CompanyName Q 3 ft. 6�/() in t I g eS 6-11V
t_ f
�f �1 16.INNER CASING OR TUBING(geothermal ciosed-loop) l
2.Well Construction Permit#i 3. FROM TO DIAMETER THICKNESS. MATERIAL
List all applicable well construction permits(i.e.UIC,County,State Variance,etc.) ft. ft In.
3.Well Use(check well use): It. ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 14,1'esidential Water Supply(single)
ft. ft. in:
Industrial/Commercial IIResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: j
© ft. g2t'� ft. `" �j�j l - e k t i'Monitoring EIRecovery ft. ft
Injection Well:
ft. ft.
Aquifer Recharge °Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft ft.
Experimental Technology OSubsidence Control ft ft.
Geothermal(Closed Loop) QTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 t� ect Crl- r
4.Date Well(s)Completed:5) -13 Well ID# 1;2 ft icy- ft. 56(4h!'ct COCK:
l ud
5a.Well Location: i jy S ft .2,t5-ft- (5((JC' 4 01411)t 1-e.
gohc G gl- It. ft.
Facility/Owner Name Facility ID#(rf app licable ft- '° � : ''30
! Sic iffy tItY�i ) J'1'�G11ifi C V ,C @ ft - i'
Physical Address,City,and Zip j ft it ��l A.
z 2 2�I C
(�1/I d��p ZL REMARKS -
1 L 1 L r .J:�i��'i:
County Pastel Identification No.(PIN) �R:4i;i1S=:::';1 . . .: r Pr7 i f 3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certificatio •PT5 //�w y /7 - - s J` 3
6.Is(are)are welts)i P rmanent or Temporary Sigma oorcec[tGed.wdttconnactor pte
By signing this form,I hereby card,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: f Yes or with 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out(must well construction information and explain the nature of the copy of this has been provided to the well owner.
repair under#21 remarla 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.Total well depth below land surface: (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
Pormultiple wells list all depths ifdifferent(example-3 200'and 2@100') construction to the following:
10.Static water level below top of casing: a b (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: I jr- i2l above,also submit one copy of this form within 30 days of completion of well
(Le. grotary,cable,direct push,etc.) construction to the following:
auger, p b
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I ,7 Method of test: 'S (1 �- 24c.For Water SuDPIV&Injection Wells: In addition to sending the form to
�( r 0,r} Z the address(es) above, also submit one copy of this form within 30 days of
i f
13b.Disinfection type: ! / Amount: Cf completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016