GW1--04403_Well Construction - GW1_20230710

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WELL CONST I U CT1 IN RECORD(GW 1) For Internal Use Only:
1.Well Contractor Information:
Chris King
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A a.90 n' , 4( ft. 5-6,i', w1,
ft. ft
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap linable) -
Aqua Drill, Inc. FROM TO /DIAMET`EER THICKNESS MATERIAL i `
Company Name O ft. ti i R- (t7 7 m. •/V I S; Id
�f 2 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: ) �S (i eIn.IV r2.7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,eta) 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 OMunicipalPublic ft. ft. In. -
Geothermal(Heating/Cooling Supply) eggesidential Water Supply(single) ft. ft. In
Industrial/Commercial E3Residential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: CO ft, ft-
Monitoring I�Recovel3�'-J�.Qr, Co.;1)5
(:Recovery ft. ft.
Injection Well:
Aquifer Recharge ft. ft.
qu g °Groundwater Remediation
Aquifer Storage and Recovery p Salim Barrier 19.SAND/GRAVEL PACK('rf applicable) -
CJ' tY FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IOStormwaterDrainage ft. ft
Experimental Technology ISSubsidence Control ft. ft.
Geothermal(Closed Loop) E3Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION[ PT (color,hardcm,soil/rock type,grata size,etc.)
// 1 4 L 6 ft /• ft &`-ef J e f1"1 y
4.Date Well(s)Completed:4t 30 ,23 Well um et it SS- ft so to d t7��c
/�Sa.Well Location:(j J ‹.6"ft .30 4Mt 13)a G / 17%�t Le-
-3 .11)73eIr- D�U; 1!aCj2s ft ft (�
Facility/Owner Name Facility ID#(if applicable) ft ft.
e1 1 $ IN) C.. r0 ft. ft RE 5.- E 1 v4.--y-
Physical Address,City,and Zip It; ft.
6/9t9)1/// ih-)°C 21.REMARKS
County Parcel Identification No.(PIN)
lb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: lD i'1 of/--~�.�ti c.wimmlit
(if well field,one lat/long is sufficient) - W . ,
22.Certification-
N W `
6 -3d _.23 ,
6.Is(are)the well(s)tiii rmanent or Temporary Signature of Certified Well Con or Date
By signing this form,I hereby certifir that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes .or 1211.No 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 i,fonnatioa 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 thisfornr.
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 GeoprobelDPT or Closed-Loop Geothermal Wells having the same
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: 3 Z. S (ft-) 24a..For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 200'and 2 a@100)
�7 construction to the following:
J
10.Static water level below top of casing: e (ft) Division of Water Resources,Information Processing Unit, 1
If water level is above casing,Use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6- On-) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: q /z )Z� ) 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) 5- Method of test: 5 i ei&N A- 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: t't 1- Amount: )4 0 Z completion of well construction to the county health department of the county
where constructed.
Fonn OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016