GW1--05579_Well Construction - GW1_20230825

4
WELL CONSTRUCTION RECORD(GW.1) For Internal Use Only: Prll t Form
1.Well Contractor Information:
Chris King
14.WATER ZONES •
Well Contractor Name OM TO DESCRIPTION
2080-A • .',I) ft: Q ft. d 14 t T'+ r... ,
NC Well Contractor Certification Number MO Ili /- ,j I. R. tZ 5- r i 19) tn
Aqua Drill, Inc. is.OUTER CASING(for multi-cased w311s).OR LINER'(if ap licable); •
FROM I TO DIAMETER ' THICKNESS MATERIAL
Company Name a n. ,7� ft" 1t i. ' ;in. 1501z,21 PiVrC
•16.•INNER-CASING' TUBING(geothermal 2.Well Construction Permit#: _6 O •
FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) ft. ft. :IL
3.Well Use(cheek well use): ft. ft. iin.
Water Supply Well: 17.SCREEN `
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
�Mutticipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply)l Ai';'dential Water Supply(single)
ft. ft. in.
Industrial/Commercial
°Residen6al Water Supply(shared) IS.GROUT
Irrigation FROM TO MATERIAL' ' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 R' 07 0 f. t3 NWk. C.,J-t 77p'.S
Monitoring °Recovery - ft. ft.
Injection Well:
Aquifer Recharge °Groundwater Remediation it
Aquifer Storage and Recovery :_19.SAND/GRAVEL PACK(if applicable) F'. „ -
LISalinityBarrier FROM TO MATERIAL 1 EMPLACEMENT METHOD
Aquifer Test EtStonnwaterDrainage ft. ft. 1. '1
xperimental Technology E3Subsidence Control
R ft
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets'if necessary) . ' -
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) t�FROM TO DESCRIPTION(color.hardness ooWrark type Wrain sae etc.)
'z 6 f. /PPct efx)y
4.Date Well(s)Completed: 2-i 2-h3vVell wit 4 ft. L 5- ft. 51,1 wj !'AcK
5a.Well Location: 14se- ft. ft 1
2 1e3 c +
ft. ft.
(--: ,`®(r-:'s Ir..
Facility/Owner Name Facility ID#(if applicable) ft, ft. 4 \l L.L.,e V L
Li
R. f.
lot)) (nog.?n .
Physical Address,City,and Zip ft. ft '
0/Z yi/1 i . . 21.REMARKS i. !7`fi rac.afl�tl Prt c Una
w
t Parcel Identification No.(PIN) D Q/B .a
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W �.. . ?'
6.Is(are).the wells eermanent or E3Temporary Signature ofCert S ell s ontractor D
y� to •
•
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or allo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standmds and that a
If this is a repair,fill out known well construction Information and explain the nature of the copy ofthis record has been provided to the well owner
repair under#21 remarks section or on the back of this fonn.
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 Geoprohe/DPT 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: 1
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) 24a.For.All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths ifdifferent(example-�0'and 2Q100) construction to the following
10.Static water level below top of casing: 3.0 (ft.) Division of Water Resources;Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to'sending the form to the address in 24a
12.Well construction method: / (fZ )7t 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 i
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /� N
Sl Method of test: c3h 24e.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 Amount: r 2 6.L 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 1 Revised 2-22-2016