GW1--05218_Well Construction - GW1_20230818

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.,WELL COI�1STtYYTCTY®ICIC®jtOD (awl=Il I Print Form,
I F It �'
ornernal Use Only: -tea
1.Well Contractor Information:
Chris King
Well Contractor Name
14.WATER ZONES
FROM TO DESCRIPTION
2080-A .3 6ft. 3E' ft. J /6-I d�p t rn ,
NC Well Contractor Certification Number 910ft• (.1 at ft. ( ( 7,i p,l��
Aqua Drill, Inc. IS.OUTER CASING(formal'easedwens)ORLINER(If ap Roble)
FROM TO DIAMETER ' THICKNESS MATERIAL
Company Name :) 1
6 I O ft. I! VC/ hi' 151)(2 2 i yr U-d e
2.Well Construction Permit#: �.ry 16.INNER CASING OR TUBING(geothermal dosed-loop) t
List all applicable well construction permits( C—��St�e,V Variance,
e, 5 FROM ft. I TO f6 DIAMETER In. THICKNESS MATERIAL
3.Well Use(check well use): ft. ft: in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/PubGc
Geothermal(Heating/Cooling Supply) ° ft. ft. in.
tDS PP y) residential Water Supply(single)
Industrial/Commercial ft. ft. In.
Residential Water Supply(shared)
Irrigation 18.GROUT
Non-Water Supply Well: FROM TO MATERIAL EMPLACEMENT METHOD SrAMOUNT
0 ft'
Monitoring LO it. ++----
Injection Well:
�oiled: �S
51,Recovery
R. ft.
Aquifer Recharge °Groundwater Remediation ft. ft.
Aquifer Storage and Recovery ;i Salinity Bailie: 19.SAND/GRAVEL PACK(if applicable)
Aquifer Test FROM TO MATERIAL EMPLACEMENT METHOD
OStormwater Drainage ft. R.
Experimental Technology *1 Subsidence Control
ft. f6
Geothermal(Closed Loop) °Tracer 28.DRILLING LOG(attach additional sheets if necessary)
(Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,boldness soil/rocktype.grain size.etc.)
Geothermal(Heating/Cooling Return)
P) ft. 3 ft. *7 e �
4.Date Well(s)Completed:V". --,1 j Well ID# ft. 9 ft. (s`in) d r_
Se.Well Location: C t tt. 5 f6 -
`f c
43udc / l �3 toe *� I«l �
L' l' 1.�5�1'1J t6 ft.
Facility/OwneirName Facility ID#(if applicable) ft. ft, ra
et. ft.
Physical Add__rejjss,City,and Zip ft. it. A 1't Ll 23
Rii
El.REMARKS
County Parcel Identification No.(PiN) re. 1,rt;g
Aisle 174".-.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certification:
N
W /fie/;, j 6.Is(are)the well(s) grmanent or Temporary Signature of Certified Well Contractor Da r -
Date
nstructed in accordance
7.Is this a repair to an existing well: DYes or .1 o w with ISA+NCAC 02C.0100 g this form,I hereby
r ISAlNCAC 02C,that the.0200)Well Construction was 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 thews!!owner.
repair under#21 remarks section or on the back of this font:.
23.Site diagram or additional well details:
6.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: 5-0 ,5 (R)
ifd :rent(example-3 a(,200'and l(a)J00') 24a' For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths
�` l construction to the following:
10.Static water level below top of casing: (c^ C (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+"
4i� 1619 Mail Service Center,Raleigh,NC 27699-1619
ii.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: ��'R d iZ J l 1 •
it 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) Method of test:7); CI\'} 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: h T \--1- Amount: 1 6 1,1 z_. completion of well construction to the county health department of the county
where constructed.
Form GW-1 o
North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016