GW1--01566_Well Construction - GW1_20240308

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WELL CONSTRUCTION RECORD(GW-1") For in " - - Print Form
ternal Use Only: I` '
:I.Well Contractor information: ' . I •
Chris King ' •
. 14.WATER ZONES"
Well Contractor Name •
•FROM TO DFSCRIPTON" -
2080-A' rr:.� " ft:.
NC•Well Contractor Certification Nianbcr ft' ft'
Aqua Drill, Inc. 15.OUTER CASING(for multi eased wells)OR LINER(if op linable)
'.FROM- TO DIAMETER .THICK.NFSs- MATERIAL - '
Company Name 0. fit: I-�J O ft / /%. '1n.'IS .
2.Well ConstracHon Permit#: `1" • . . 16.INNER CASING OR TUBING(Reoth'ermaldosed-loop) "
•� ./ /� . - .FROM' 'TO_ • DIAMETER - . -THICKNESS MATERIAL .. ..
List all applicable well constntclion perot, (i.e.UIC,(amity State Varm,zc'e etc). ••
3.Well Use(check well - - : ft.• ' . . ft:' ,In,.
Water Supply-Well:- - IL SCREEN - " _
Agricaiti,tal . . '
FROM. - TO . - • 'DIAMETER' SLOT SIZE . 'THICKNESS MATERIAL '
�Municipal/Public ft: - - in
Geothermal(Heating/Cooling Supply) Residential Water Supply(single): :
•Industrial/Comrnercial- ft' ft. i�
.Residential.Water Supply(shared)" - " " '
irrigation• 18 GROUT
- FROM: - TO " . - -- MATERIAL. EMPLACEMENT METH 013
'Non-Water Supply Welk -
R." ^ ft•
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fJ( • t
Monitoring t".
•"0 Recovery. .. 't.: - de.. s a . .
:injection Well: : fit.:
Aquifer Recharge - - - . DGroundivatcr Remediation ft'
Aquifer Storage and Recovery. 'Salinity-Hairier .• 19:SAND/GRAVEL PACK-((fapplicable). .
.FROM - 'TO. -MATERIAL -EMPLACEMENT METHOD
Aquifer Test .OStornlwaterDrainage ft. ' It "
Experimental Technology OSnbsidence Control :ft.
Geothermal"(Closed Loop) Tracer- 20:DRILLING LOG(attach additional sheets if necessary)'
Geothermal(Heating/Cooling Return) FlOther(explain:under#21"Remarks) .FROM To DESCRIPTION learns,hardness
sotumekevpe, •
cram sl a ale)
4:Date Well(s):Completedyg '/C""a:C/Well1D# ft, ft,• �� '
Sa."We1lLocation: �"-1
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Facility/Owner Name. i", .-, :.
Faoility ID0(if applicable); . • . . ft..I :"ft- 5 5 j
Par)1 [. J2G't- ' _7vtI;At.)R"jf" 1,Q. iC - tit:.' . its
'Physical Address,City,:and Zip M cI K +� ?i1Ly
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. lr�n-� 21:REMARKS • tIt{'oi s77.7,::P'1 7D.•-... .
..L.-t^d:
County •
- :Parcel Identification No.(PIN). - . - OW 7 ..: A
• . Sb.Latitude and longitude In'degrees/minutes/seconds or decimal degrees:, " • • - -I
•(if well field.One lst/long is sufficient) •
22.Certiflca' n:
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6.Is(are)the well(s) Permanent.' .or'QTemporary Sig urc of Certified Well Corinne
Date
• 'By signing thi 's form;/herein ccsrt/drat the well(i)was'(acne)consnvded in accordance
7:Is this a repair to Aire. Q
xisting well:- Yes 'or.610 • • - u(th ISANC-ICO2C:0100 or%54 NCACWC.0100'iVell Consirucilon Standards and thee a
.If this IA a repair,fill out!Maori.well consrnrcilon inffmpmtlon and explain lhc•nature'ofthe "copy of this record has been provided In the urll owner.
"repair under#22remarks'secilon or on the back ofthls:form..
23.Site diagram or additlonal.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:-
SUl;N1iTTAL INSTRUCTIONS . ,
9.Tatal well depth below land surface: • a"2'5— • •• (fit• •)' 24a."For All Wells: Submit this form within'30.da.days corn letton of well.
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For multiple wells list all depths ifd jlTerenl(example:3@200'and 2@100r • ' y p
construction to the'following
10.Static waterlevel below top of.easing: . - " ", (ft.) .Division of Water Resources
If water level is above casing..use--+" ,information Processing Unit,
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1617 Mail-Service.Center,Aidelgh,NC 27699-1617 •
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11.Borehole diameter: <O. . •(ln:). 246:.For Injection Wells: In addition'to sending the'forn to the.address in 24a'
t ` above,also(submit one copy of this form within 30 days of completion of well
12.Well construction method:4,., ),.. :an.l :,-1.(i.e.auger,rotary,cable,direct push; 11 construction to the following: .
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• ' FOR WATERSUPPLY:VVELLS ONLY: Division)of Water Resources,Underground Injection Control Program,.
` 1636 Mail Service Center,;Raleigh,NC•27699-1636
• 13a.Yield(gpm). 'ST__. Method of_test:" 19 l j - 24c..For Water Sunnis, Injection Wells:'In addition to sending the form to,
136.Disinfection Ja the addresses),above,"also:submit one',copy"of"this form within.30 days of • '
type: T I Amount:') 4G'Z- :completion lof"well construction to th county'health department'of the county "
where constructed.•
.Farm GW-1. • •North Carolina Department of Environmental Quality--Division-of Water,Resources
""Rcviscd.2-22-2076
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