GW1--03598_Well Construction - GW1_20230522

Print Form-
WEILL
ONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King '14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A ft �W ft.
ft ft.
NC Well Contractor Certification Number 15.OUTER CASING for mulH-cased wells OR LINER(illato licable
Aqua Drill, Inc. FROM I TO DIAMETER THICKNESS MATERIAL
6 C/ ft. 6, � in. . �4
Company Name � If'
16.INNERCASINGORTUBING eothermidclosed-loo
2.Well Construction Permit#: 7-9 — ) 6 (, FROM To I DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. fL in.
3.Well Use(check well use): ft. fL
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. & in.
Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft. ft. In.
Industrial/Commercial Residential Water Supply(shared) 48.GROUT
hri tion FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft.
6 ft-
-
Monitoring Recovery ft. ft.
Injection Well: ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a linable
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
- Aquifer Test DStotmwater Drainage ft. fL
Experimental Technology OSubsidence Control fL &
Geothermal(Closed Loop) E3Tracer =`20.DRILLING LOG Mach additional,sheets ifnecessa
Geothermal(Heating/Cooling Return) ± Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillroek type,grain size,eta)
ft '9 ft I
4.Date Wells)Completed: V 6 12 31We11ID# ft, j s— ft J fbG C
So.Well Location: ft' 92 S rt 4(f
ft. fL
Facility/Owner Name Facility ID#(if applicable) ft. fL {.r•.� ,.'u..`} a •' ,;
Physical Address,City,and Zip % IL tAY 2 r
Pe fZ 5 a ti r2L RENIARKS r
County Parcel Identification No.(PIN) r a )'i^_•`'.�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:N W
6.Is(are)the well(s)OP-manent or OTemporary Signature of Certified Well Contractor Date
By signing this farm,I hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EJYes or ANo with I5A 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 erplain the nature of the 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:
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: S� (R) 24a.For All Wells: Submit this form within 30 days of completion of well
For in ltiple wells list all depths if different(example-33@200'and 2@ 100 5 construction to the following•
�
10.Static water level below top of casing: `�0 00 Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (in.) 24b.For Iniection Wells: in addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: ��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 276994636
13a.Yield(gpm) .2— Method of test::5 T 24c.For Water Supply&Injection Wells: In addition to sending the form to
/ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: LI, 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