GW1--06204_Well Construction - GW1_20230925

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WELL CONSTRUCTION RECORD(GW-1) For t— - -
Internal Use Only: !I
1.Well Contractor Information:
Chris King
14.WATER ZONES I 1
Well Contractor NameFROM TO DESCRIPTION
2080-A _ ft. — ft. , i # J•'i �t�1
ft. ft. t�
NC Well Contractor Certification Number
Aqua Drill, Inc. 15.OUTER,CASING(for multi-cased welts)OR LINER•(if ap livable)
FROM TO DIAMETER THICKNESS MATERIAL
Company Name O ft. 96 ft. e' 3
er AA/
Pt-, ` , � , 16.INNER CASING OR TUBING:(geothermal closed-loop)'2.Well Construction Permit#: �/l.l,e-�1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. C.County,State,Variance•etc.) ft. ft. i in.
3.Well Use(check well use): ft. ft. I in.
17.SCREEN
AgriCultUl'alWaterSupply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Mtaiunicipal/Public ft. ft. in.
Geothermal(Hcating/Cooling Supply) !I;, • idential Water Supply(single)
ft. ft. is
Industrial/Commercial f Rcsidcntial Water Supply(shared) ...
'Irrigation 18.GROUT •
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
0 it. `� O IL i3G iu Ile cA S
Monitoring QRecovcry ft. `"' ft. \
Injection Well:
Aquifer Recharge ®Groundwater Remediation ft. ft. —
Aquifer Storage and Recove 19:SAND/GRAVEL.PACK(ifapplicable). . " . -
rY OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) ©Tracer - .;20.'DRILLING LOG(attach additional sheets if necessary) - `
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size etc.)Q' a ft. '; ft. geed I.0 m. v
4.Date Well(s)Completed:—D 23 Well ID# 3 ft. Li ci ft. 5 AK) !/c e'
CC
5a.Well Location: CIO ft. css- ft. 13no,e__I up
12Iz am 5yM•1 s3 s- ft. 5- g- t. 131 u e' Fs f21 c-6c
• Facili • ncr c Facility ID#(if applicable) ft. ft.
.)4 &S 5par(: E_Q c so;1.1k 1 ft. ft. P � -.v r-
Physical Address,Cit,and Zip ft. ft. ! ' Z ai ►,. 4...fir'
, /Q �\ .21.REMARKS-
Coanty SE° w .,L3
Parcel Identification No.(PIN)
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: IfiiJ;:AP'atis 1 Prr,C g Vrk
(if well field,one lat/long is sufficient) 22.Certifi lion: ,.w
9 -3 --2 3
6.Is(are)the well(s)i!/tf4termanent or �ITemporar} Signature of Certified Well Contmc r Date
tv7" By signing this form,/hereby cer!j/'that the I well(s)was(were)conctnicred in accordance
7.Is this a repair to an existing well: [JYes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C,10200 Well Construction Siandards and that a
If this is a repair,fill out known well construction infirmation and explain the nature of the copy of this record has been provided us the well owner.
repair under#21 remarks section or on the back rfthis farm.
23.Site diagram or additional well details:
8.For Geoprohe/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: S I
For multiple wells list all depths.Ifd Brent(example-3(r�y00'and Z(a)!UU) (f t') 24a, For All Wells: Submit this form!within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: i® (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: v
(in,) 24b.For Injection Wells: in addition to(sending the form to the address in 24a
12.Well construction method A i Z %Zj 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,
i 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gym) Method of test: 3 a �' 24c.For Water Supply&Injectlon Wells:; In addition to sending the form to
the address(es) above, also submit one c p'y of this form within 30 days of
13b.Disinfection type: J 7 `7 Amount: l6 6 z completion of well construction to the county health department of the county
where constructed. I
Form GW-i Nord;Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-20 i fi