GW1--05014_Well Construction - GW1_20240827

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I______
1.Well Contractor Information:
Chris King
14,WATER ZONES
Well Contractor Name -70FROM TO DESCRIPTION g Cp•
2080-A t• ,17i ft. I 1 i 0'1
ft. ft.
NC Well Contractor Certification Number
Aqua Drill, Inc. 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
TO DIAMETER THICKNESS MATERIAL
Company Name FROM0 ft. (f l ft. / //cl in, ,.1 Sv /�/v
/ iJn )CL�� r , FR,INNER CASING OR TUBING
ThermalclICKNIESSS Cjr
2.Well Construction Permit#:ldJ�(1! �+ `•� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UDC,County.State.Variance,etc.) It. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
DAgricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DMunicipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply)6% nkt&esidential Water Supply(single) t.
ft. ft. in.
JIndustrial/Commercial DIResidential Water Supply(shared)
18.GROUT
)irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 ft.• fft. ''qq �AL /� —
DMonitoring QRecovery ft. ft. vt°tiTlur C1�/�
injection Well:
Aquifer Recharge OGroundwater Remediation ft. ft
Aquifer Storage and Recovery DSalinity Barrier 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft. —
OExperimental Technology QSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
IDGeothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sire.etc.)
4.Date Well(s)Completed:5 s;NQ;29 Well ID# ft. ft.
5a.Well Location: ` �ft. ���{ �t7
�, ft. jU..�— /,,zi
ram
ft. ft. w�, P
Facility/Owner Name Facility ID#(if applicable) ft. ft.
i d L/ -50 L+I'l e—T110 /1'7 Se Is rr.C7 ) g(. ft. ft.
Physical Address,City,and Zip ft. ft./ 1 n A7 A ry c e 21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _
(if well field.one lat/long is sufficient) 22.Certification:
N W - a --I
6.Is(are)the well(trPermanent or Temporary Signa o Certified Well Contractor Date
By signing this form,i hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: IDYes or'No with/5A NCAC 02C.0/00 or/SA NCAC 02C 0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information�a plain the nature Of the copy of this record has been provided to the well owner
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.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 LNSTRUCTIONS
9.Total well depth below land surface: 30 (ft-)
For multiple wells list all depths if different(example-3(a3200'and 2@100') ons c 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: 0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+'•_
(� 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)
24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method / CIA;1 l above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct pustt,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
�/ 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) U Method of test: Ski .3- 24c.For Water SUDDIV&Iniection Wells: In addition to sending the form to
J, {p/ I the address(es) above, also submit one copy of this form within 30 days of
/7
I3b.Disinfection type: 7L/ Amount: / 0 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources