GW1--06317_Well Construction - GW1_20230926

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1
I.Well Contractor Information:
Chris King 14.WATERZONES I i
Well Contractor Name FROM TO DESCRIPTION
2080-A J.,) 6 ft' )3 ) ft' 30 IG i PI
ft. ft.
NC Well Contractor Certification Number
15:OUTER CASING(for multi-casedVwells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL`�
Company Name Q ft. /S ft. / .A1.i in. . g 2 1 pi v J c
_ ^ C)7 _� 16.INNER CASINGH OR TU[BtI?NG,(geothermal closed-loop), __
2.Well Construction Permit#:))5j41 j `0! li 0 A FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Couno.,State,Variance,etc.) ft. ft. 'in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17:SCREEN
A cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Municipal/Public ft. ft. in.
°Geothermal(Heating/Cooling Supply) 25Rcsidential Water Supply(single)
fL ft. in.
0Industrial/Conuuercial °Residential Water Supply(shared)
18.GROUT
Irrigation - `--:
FROM. TO MATERIAL EMPLAC MEMETHOD NT &AMOUNT
Non-Water Supply Well: ft. ft. 1'' .
Monitoring °Rccovcryi3ti� !e ��
ft. ft.
Injection Well:
Aquifer Recharge ft. ft.
QGroundwater Remediation '
Aquifer Storage and Recove '.19:SAND/GRAVEL PACK(if applicable)''.'. - ' - - - .
ty °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology8
I�Subsidence Control it. ft.
Geothermal(Closed Loop) Tracer
20 DRILLING•LOG,(attachaddItionesheetsit necessary) _
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 ft. 3 ft, fz e )P4 V
4.Date Well(s)Completed: ;22-23 Well ID# 3 ft. f!o 6 ft. 5 0,10 d jZc cK._1/4
Sa.Well Location: ".b ft. /C� It.
.\N. 2n�.cct - ft. ft.
Facility/Ownery/ Name/ �J Facilityy_ iD#(if applicable)
ft. ft.
° " ' t Y f I j PK \1 1 1`a t -{L1cJ1 \'f��1 kNe.t , ft. ft.
Phycjcal Address,City. nd Zip ft. ft. T n >" 4 ' .
21:REMARKS: //
County Parcel identification No.(PIN) sEp 6 20 L3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ;.7..n l)rY
(if well field,one lat/long is sufficient) 22.Certification: ` -r:VX211, -
iT1w� lik!a>,,1.r,-'Lo
N W 9-, 22 -23
6.Is(are)the well(s)'koliPermanent or EjTemporary Signature of Certified Well Con actor Date
By signing this form,I hereby certify that the wull(s)was(were)constructed in accordance
7.Is this a repair to an existing well: IDYes or Akio 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 explain the nature of the copy of this record has been provided to die'well owner.
repair under#21 remarks section or on the hack of this firm.
23.Site diagram or additional well details:
You may use the brick of this page to provide additional well site details or well
8.For Geoprobe/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: V
CS j SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ) �j (ft-) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iil ddetent(example-3@200'and 2®100') construction to the following:
N.Static water level below top of casing: v
If water level is above casing,use +" (ft.) Division of Water Resources,iInformation Processing Unit,
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: ) , �Z i above, also submit one copy of this form within 30 days of completion of'well
construction to the following:
(i.e.auger,rotar
y,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) `! Q Method of test: D i q h 4 24c.For Water Supply&Injection!Wells: In addition to sending the form td
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: ))Tk) Amount: (1� completion of well construction to the icounty health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016