GW1--04687_Well Construction - GW1_20230721

WE'LL CONSTRUCTIILIN RECORD(GW-1) For Internal Use Only: ` Form
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I.Well Contractor Information:
Chris King
• 14.WATER ZONES y 1
Well Contractor Name FROM TO DESCRIPTION
2080-A I Se, ft. 55 ft. ,A3 t-r R rn
NC Well Contractor Certification Number ft. ft.
Aqua Drill,Inc. IS.OUTER CASING(for multi-eased welts)OR LINER(if ap licnhle)
FROM TO/ DIAMETER THICKNESS MATERIAL
Company Name O R. I G'3 f• 11�'l'cg"ta. I t f 3 6- J(
/
�; f� `> 16.INNER'CASING ORTUBING(geothermal closed-loop)
2.Well Construction Permit#:4p -.4 0
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 it in.
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL�MunicipalPublic R. ft. In.
Geothermal(Heating/Cooling Supply) Mesidential Water Supply(single)
ft ft in.
Industrial/Commercial DResidential Water Supply(shared)
Irrigation 18:GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: / ft. it
Monitoring !- Recove (2 sClrs��/4a Ch1 S
Injection Well: ry ft. ft
Aquifer Recharge OGroundwater Remediation ft. ft.
Aquifer Storage and Recovery ()salinityBarrier19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IOStormwaterDrainage ft. ft
Experimental Technology 0Suhsidence Control ft. ft.
Geothermal(Closed Loop) f ITracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Ieating/Cooling Return) fj Other(explain under#21 Remarks) F T ft.
TO ft. DESCRIPTION(color,'hardness,soil/rock type,grain size,etc.)
/.cd clay 4.Date Well(s)Completed:2'-S 2 3 Well lD# 6 R. v r ft. 5A)vd izd G IC
5a.Well Location: ft.
!//l� 5OfVG ft, ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft
‘L//G N e., C 7 Ie 0 tJq a fh.,,rj `J ni x ft. ft. II ▪ W
Physical Address,City,and Zip 5-7� ft. ft + r
OR0KJc 21.REMARKS JIJ L e� �! Ti
County 1 Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: jnlpfe^toi.t:D r,isrwa k� 1f�1
(if well field,one tat/longis sufficient) i• �'
22.Certift ation:
N W �`. 126.Is(are)the we0(s) Permanent or Temporary Signature of Certified Well Conk ur 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: D Yes or DNo 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 explains the nature of the copy of fhb record has been provided to the well owner.
repair under#2l remarks section or as 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: I q S (f.) 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@100)
construction to the following:
10.Static water level below top of casing: SO (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+"
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: CP (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12 Well construction method: (j`j �2l` ) L 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,
1636 Marl Service Center,Raleigh,NC 2 7 699-1 63 6
13a.Yield(gpm) 1 5--- Method of test: 5(C( h+ 24e.For Water Supply&Injection Wells: In addition to sending the form to
/ �i the address(es) above, also submit one copy of this form within 30 days of
I3b.Disinfection type: , /j Amount j Q -, 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