GW1--04397_Well Construction - GW1_20230707

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: -
-1.Well Contractor Information:
Chris King
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A ?c70 ft. , .7/ ft Ida G/ l' irl
ft. ft.
NC Well Contractor Certification Number
' 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS (I MATERIAL
Company Name O ft // K C� Ye ro. I j' I 6/4
I ( 9
r 16.INNER CASING OR TUBING(geothermal closed-loop) (J i(�
2.Well Construction Permit#:,�� L�l �� �,2 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): ft ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Agricultural °Municipal/Public ft. ft. in.
°Geothermal(Heating/Cooling Supply) (Residential Water Supply(single)' ft. ft. in.
Industrial/Commercial °Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft. aid ft- oemeN-- f zv C/c
Monitoring °Recovery ft: ft / J
Injection Well:
ft. ft.
[3Aquifer Recharge °Groundwater Remediation Aquifer Storage and Recovery �q Salini Barrier 19.SAND/GRAVEL PACK(if applicable)
J' tY FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test °Stormwater Drainage ft. ft.
Experimental Technology °Subsidence Control ft. ft.
°Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
°Geothermal(Heating/Cooling Return) !Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soit/rock type grain sve etc.)
�1 / 0 ft. 3 Zed e1wV
4.Date Well(s)Completed:( "7/0 ,2 Well LD# C,3�0 3 ft IS- f t. 5 A 6UGI (ZO cC
5a.Well Location: As-- ft. 310 ft. Slue rt iq J()i-t e
ft. ft.
Facility/Owner Name Facility 1D#(if applicable) ft. ft. ?,�" a
r. % v.zr 'irlJy
c-Ir2c7 ,1 14vdiztz, ' PL ft r ' �e . .
Physicalys Address,City,and Zip tt ft I. l © 7 !Cl t
!H'� th/4�,Ui,P 21.REMARKS
r '1C.1;�r.-1.r�y1,ga:.g us-,..4. i
County Parcel Identification No.(PIN) infr tt~" ,.}a,,,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latfong is sufficient) 22.Certification:
N W 6�ti"�Y" ry
C'/4-QCS
6.IS(are)the well(s)%j�iPerntanent or °Temporary Signature of Certified Well Contractor Z____.:;
Date
t By signing this farm,I hereby certi&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or pixo with ISA NCAC 02C.0100 or ISA 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 of this 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:
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: VD (ft.) 24a.Foe All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@2200'and 2@100') construction to the following:
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,msse//+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: C> (in.) 24b.For Injection 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:/9 f/? di?)j) construction to the followin
(i.e.auger,rotary,cable,direct push,etc.) g
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)_100 Method of test:5iCi h.} 24c.For Water Supply&Infection 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: 1/77/ Amount-�[� z 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