GW1--06283_Well Construction - GW1_20230926

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER'ZONES: 1 ;
Well Contractor Name FROM TO TO/ DESCRIP„„TION-
t oft. 2c 1 ft.
a/®,�7
2080-A ,e i an
ft. ft.
NC Well Contractor Certification Number
15;OUTER:CASING(for mtilti,cased wells)IOR LiNER(if ap licable) '
qua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0ft. 12( ft. / .Y� in. 5 i\re 21 �, j.0c - f t
'16.'INNER CASING!OR TUBING(geothermal closed-loop), .., .. l'.
2.Well Construction Permit#:� 9� 76 2 FROM TO DIAMETER' THICKNESS r MATERIAL
List all applicable well construction permits(i.e.UIC,County.State.Variance.etc.) ft. ft. in.
3.Well Use(check well use): ft, ft. in.
Water Supply Well: 17.SCREEN_ h
Agricultural FROM 'TO DIAMETER. SLOT SIZE THICKNESS MATERIAL
?ri °Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Rtsidcntial Water Supply(single)
ft. ft. in.
Industrial/Commercial °Residential Water Supply(shared)
18.GROUT
Irrigation .. _ _ •
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: C) ft. 020 ft. ?win 4.0 c'k t c
Monitoring `
0Recovery ft. ft. , •
Injection Well:
ft. ft.Aquifer Recharge ®Groundwater Remediation A uifer Storaa and .d9.'SAND/GRAVEL PACK(if applicable),-' '• '- : '
q $ Recovery °SalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test °Stornlwater Drainage ft. ft.
Experimental Technology 01Subsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer :20.-DRILLING;GOG_(attach additional-sheets ifnecessacW -.. 7..
Geothermal(Heating/Coolin FROM TO DESCRIPTION(color,hardness,soil/rock type,groin size,etc.)
g Return) °Other(explain under#21 Remarks) © ft. �2 7 ' Lr l'a /ft. `
4.Date Well(s)Completed:2( q..5 Well ID# 3 R• I k S"ft" S A 1U d tZOC K
5a.Well Location: t 1 j, l
f!�r • e i ))5-ft. I.LS'ft• 2 e:t 1 1 e.l ‘ .
Facility/Owner Name Facility ID#(if applicable) 26&ft• 5fL
,Lib'.ILA y bV jz c h 2Z f ocIC5d 1 )f G ft. ft. • ' i^�' .-c '\: �'
Physical Address,City,and Zip •I'vr C ft. ft. ; "•••'
n q
AV?i./j -21.REMARKS . __ J[P 9' g Lui-J '
.,
County Parcel Identification No.(PIN) .ftei ItnI
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 4Mr 't`"'` .,•^,:;i
(if well field,one lat/long is sufficient) v
22.Certification:
N W -
21
t nature of Certified Wcll C" ontractor " - -
6.Is(are)the wll(s) ermanent or Temporary g Da e
�1�{,�,, By signing this,fain,,I hereby cent*that the well(s)nos(were)constructed in accordance
7.Is this a repair to an existing well: DYes or itom"e- with I5A NCAC 02C.0100 or 15,4 NCAC 02C.0200 Wel!Construction Standards and that a
if this is a repair,fill nut known well construction informatiar 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 hack 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: e. v t (ft.) 24a. For All Wells: Submit this i form within 30 days of completion of well
For multiple wells list all depths dfdierent(example-3@200'and 44100')
construction to the following:
10.Static water level below top of casing: 5-CD (ft.) Division of Water Resou'ces,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 2 769 9-1 61 7
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: /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:
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FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) rS 0 Method of test: 5 i 9
h'\ 24c.For Water Supply&insiecti I n.Wells: in addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days otf
13b.Disinfection type: )\'t\4 Amount: '1 0 Z- completion of well construction toll the county health department of the county
where constructed.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016