GW1--04401_Well Construction - GW1_20230707

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WELL CONSTRUCTION RJECI'R D(GAY-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A A7o ft. .27/ ft. iv o
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER Of ap Iicable)
Aqua Drill, Inc. FROM - TO DIAMETER THICKNES3
TRIAL
0 rt. C1Z ft. /_ in, ,166 Company Name v
/�/ ' P 16.INNER CASING OR TUBING;(geothermal closed-loop)
2.Welt Construction Permit f✓GfJ�L/v �� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits rte.VIC,County,State,Variance,etc.) ft ft. tn.
3.Well Use(check well use): ft. it In.
Water Supply Well: 17.SCREEN
Agricultural MuniCi al/PUbiiC FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
® P ft. ft. in.
Geothermal(Heating/Cooling Supply) ,:'Residential Water Supply(single) it ft in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O it rJ ft. i riv-1N,1-lc d J(!(7 5
Monitoring °Recovery ft. �` ft. / t I
Injection Well:
Aquifer Recharge ft. ft.
arg (°Groundwater Remediation
Aquifer Storage and Recovery19.SAND/GRAVEL PACK(If applicable)
g °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test i°Stormwater Drainage ft. ft
Experimental Technology (°Subsidence Control ft. ft.
Geothermal(Closed Loop) j jTracer 20.DRILLING LOG(attach additional sheets;itneeessery) -
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness,soll/tocktype,grain size,etc.) '
€/ g nOther(explain underer#21 Remarks) ft. 3 ft.
:6 — 3'Well ID# �--�"5 C ��(l
4.Date Well(s)Completed G�7 �� � ft pS- ft* S�d l t cr.
Sn.Well Location: iS•- it X/2�,5-- ft 416C, o/Zvli- .
(.1.Tiint ct i1 .1.Iyli'tcli it .-S 1 L e ft. ft
Facility/Owner Name Facility ID#(if applicable) IL ft.
5,5;2 Siglee l azsats 01z t1. ft. ,�-r,r: °a f r;4
Physical Address,City,and Zip ft. ft. '" " s.a,^�;
/414/41 g-/at✓ 21.REMARKS JI ji 0, 7 2023
County Parcel Identification No.(PIN)
' de in d I n i tr-T Sjcn Pr r•':::;,Or�;;F.,j UrTa 56.Latitude and long
degrees/minutes/seconds or decimal degrees: r^a' •V."....
(if well field,one 1at/long is sufficient) 22.Certification:
v,y..a W
N W
6.Is(are)the wells rmanent or °Temporary , Signature of Certified Well Contmcto Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or(EVo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fdl out known well construction h formation and explain the nature of the copy of this record has been provided to the well owner.
repair wider#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW i is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
0-5—
� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths((different(example-3@200'and 2@100)
�� construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processin Una If water level is above casing,use--2,-" g t,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6- _�( (in.) 24b.For Inieetion Wells: In addition to sending the form to the address in 24a
12.Well cons action method: ) c�1Zl l t above,also submit one copy of this form within 30 days of completion of well
-
(i.e.auger,rotary,cable,direct push,etc.) 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) I 0Method of test: 5 ('Gn i 24c.For Water Supply&Injection Wells: In addition to sending the form to
1�f 1 f the address(es) above, also submit one copy of this form within 30 days of
tYp
13b.Disinfection e:! I4 Amount: I(¢ 0 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