GW1--04309_Well Construction - GW1_20240722

WELL CONSTRUCTION RECORD (GW-1) For internal Use Only: t
I.Well Contractor Information:
Chris King
14,WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A /55
_,ft' i 5 7 fL 5 1 t't 4''1_
ft. ft.
NC Well Contractor Certification Number _
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM To DIAMETER I THICKNESS MATERIAL
1't• �� ft. f(C in. 5 i7/2 -\
Company\ante r_ ,I / i t.- L-
16.INNER CASING OR TUBING�(geothermal closed-loop)
2.Well Construction Permit#:‘O(57t'J- (el, i1 T? L FROM Ti) DIASIETFR THICKNESS MATERIAL
List all applicable»ell constriction permits(i.e. U/C.Counts.State.Variance.Li FROM
rt. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN _
FROM TO DIAMETER SLOT SIZE I THICKNESS i MATERIAL
Agricultural 111 Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) ,t1 :`csidential Water Supply(single) •
ft. ft. in.
Industrial/Commercial DRestdential Water Supply(shared) —
18.GROUT
irrigation FROM TO MATERIAL EMPLACEMENT METHOD
Non-Water Supply Well: ft. ft. /7 , p 5 /` ��
Monitoring Rccovc � i )CiJ,yyZ:, }C I l S L
injection Well:
ft. ft.Aquifer Recharge 0Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO M.ATERI.Ai.-- EMPLACEMENT METHOD
Aquifer Test IDStormwater Drainage ft. ft.
Experimental Technology 0Subsidence 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 sew.etc.)
�7 C ft. /' ft. �i; 5ee
4.Date Well(s)Completed:) /�'';z Cl Well iD# ,' �l p
it. ��2 �\ ft. SN i;�l L R-lt C
5a.Well Location: t O. ft. J S-ft. '
ft. ft.
/5�t!c G�.Nh:I4F
Facility/Owner Name Facility ID#(if applicable) ft. ft. -n
g c -50 +Rz�, I d-.�- � b»t, E� c fL
Cc _ ,I;� i ,=;4-t
Physical Address.City,and Zip ft. ft.
//A h-/1 re 21.REMARKS
County G 1 Parcel Identification No.(PIN) ` ;d' "
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one laulong is sufficient) 22.Certification:
N W
6.Is(are)the well(s)gEermanent or OTemporary Signature of Certified Well Contractor Date
By signing this ftrrm,1 hereby certify that the arc//(s)tens(were)constructed in accordance
7.Is this a repair to an existing well: El Yes or,Ilia with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constr etion 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'he well owner
repair under#2/remarks section or on the back(Obis farm.
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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
'7 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3.AC .S� (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(tp200'and 20000')
construction to the following:
10.Static water level below top of casing: (c, (l (ft.) Division of Water Resources,Information Processing Unit,
/fware,level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: C (in.) 24b. For Injection Wells: In add lion to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: Pia/Z ( iZI `' construction to the following:
(i.e.auger,rotary,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
I3a.Yield(gpm) 5 Method of test: ; Q• 1 j.� 24c. For Water Supply& Injection Wells: In addition to sending the form to
L the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type:y/f Amount:) 6.� 7_ completion of well construction to the county health department of the county
where constntctcd.
Form GW-I North Carolina Department of Environmental Quality-Dixision of Water Resources Revised 2-22-20I6