GW1--03599_Well Construction - GW1_20230522

WEIt.L ®1VSTRUCT'I,I PI RECORD(G�1) Print Form
For Internal Use Only: t `—
1.Well Contractor Information:
Chris King
14.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION
2080-A 5- ft. ft. S-•—° G(f tM
NC Well Contractor Certification Number ft.
Aqua Drill, Inc. IS.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. J ft. C IA( in.
I5 P z z k_ ?Rif t C
2.Well Construction Permit# 16.INNER CASING OR TUBING(geothermal closed400p)
List all applicable well construction permits�U!C,`County State,�y� �j FROM R. TO ft. DIAMETER in. THICKNESS MATERIAL
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OMrmicipal/Public ft if, in.
Geothermal(Heating/Cooling Supply) r Residential Water Supply(single)
Industrial/Commercial ft in.
Residential Water Supply(shared)
. Irrigation IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: © ft-
�Q ���1' "'f t
Monitoring Recovery ` '1-�� h i 5
Injection Well: ft. ft.
Aquifer Recharge I°-Groundwater Remediation ft.
Aquifer Storage and Recovery °Salimty Barrier 19.SAND/GRAVEL PACK(if applicable)
FROHL TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwaterDrainage it ft.
Experimental Technology QSubsidence Control
ft. ft.
Geothermal(Closed Loop) OTracer '20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Fieating/Cooling Return) Other(explain under#21 Remarks) ORi TO pDESCRiFtION(color,names sotvm�en,�grain size.etc.)
4.Date Well(s)Completed:.{'f C)" O ft 3 � t�cr i Cr i l
J ^ .2 j Well ID# ft. ft.
.� �z 541v f i2��.K 5a.Well Location: J ft, ^/6S tL /ffe / _
ft. ft
•
Facility/Owner Name Facility ID#(if applicable) ft. ft
�pia �'� `7:—..--- .,� �--�. -
`i fl1t��i'C ill 12` ft. ft � ��-r..:..i i vy.:: .
t,.e r, i Physical Address,City,and Zip
MAY 9Q1
R/Anidc)(ei 2LREMAR1CS 'w L023
County Parcel Identification No.(PIN) Irls`C;,�;.-, �,
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: "- /�i7ri
(ifwell field,one lat/long is sufficient)
22.Certification:
N w c I l
6.Is(are)the weil(spermanent or Temporary Signature of Certified We Contractor
` �v -�3
Date
7.Is this a repair to an existingwell: By signing this form,I hereby cerl(5'that the well(s)was(mere)constructed in accordance
DYes or o with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy afthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthisform.
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 I 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: /65— (
For multiple wells list all depths jfdifferent(example-3Q2Q0'and 2(a3100� II) 24a.For All Wells: Submit this form within 30 days of completion of well
construction to the following
10.Static water level below tap of casing: 2 Q
Ifwater level is above caring use + (ft.) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (7- (in.)
246.For Injection Wells: In addition to sending the form to the address in 24a
12 Well construction method �`�j 1-L d C ` \ above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER.SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
b 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test:S('(t J1-f 24c.For Water Supply&Injection Wells: In addition to sending the form to
13b.Disinfection type:_J� ( 77 the address(es) above, also submit one copy of this form within 30 days of
1--+' Amount: 0 Z-'" completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality_Division of Water Resources I
Revised 2-22-2016