GW1--05457_Well Construction - GW1_20240912

i
WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only: l
1.Well Contractor Information: •
Chris King 14.WATER ZONES '
Well Contractor Name FROM TO DESCRIPTION
2080-A (/o(: t 6/O I fL
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 THICKNESS MATERIAL
Company Name ft. cfft C`s) in. I!` g
()17
,[t 1i/
COl/ 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:CO` 0 1.....)C tgz l .2 C"1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits Re.UIC,Counv.State,Variance,etc.). ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural rjMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply)4Eesidential Water Supply(single) R. ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT -
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD Se AMOUNT
Non-Water Supply Well: ft. ft. 1
Monitoring-Watetlifur�� 1�.l p 5
0Recovery ft. ft
Injection Well:
ft. ft.
Aquifer Recharge 0Groundwater Remediation
Aquifer Storage and Recovery I Salini Barrier 19.SAND/GRAVEL PACK(if applicable)
tY FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 0Tracer 20.DRILLING LOG(attach additional sheets if necessary). ,
Geothermal(Heating/Cooling Return) flOther(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardness sait/metc type,grain size.etc.)
/O ft.
/ ft 56= 1
4.Date Well(s)Completed:% -A Well ID# ( ft. L(® ft, Sor aid /i7.,,, - i
5a.Well Location: f t d ft. (4„ f t )31 v e C31-i CZ'K�,J 4 c
-5 (` n�-4c 130-ildeit5 TV `1 ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft, ft.
C.q(l y 7 ilex e 3 A Ki r 0 nes- ea ft. ft. I_�� `.,P L.:, °" 1--L.•
Physical Address,City,and Zip ft ft. e C D 7 sA 9n73
21.REMARKS v L ..,•
County Parcel Identification No.(PIN) le rVrP-cC_o ? err.^5d4.;AR L11
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
D'I Ci$0a
(if well field.one lat/long is sufficient) 22.Certiti lion:
N W t' t1
5 -Z t(
6.Is(are)the well(s ftermanent or Temporary Signature of Cut' ed ell Contrac r Dam,2
By signing this forms.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or(ilfo 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 the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
A.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:
SUBMITTAL INSTRUCTIONS •
9.Total well depth below land surface: 82-5— (f0 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdrfferent(example-3@200'and 2@100') construction to the following:
6� 1
If Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
water level is above casing,use--1-"
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: a (in.) 24b.For Infection Wells: 1n addition to sending the form to the address in 24a
Q i f above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:/! 12 r i
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: J 1 �� 24c.For Water Supply&injection Wells: In addition to sending the form to
/^� / the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection type: ['r / Amount: 16 a 7-^ completion of well construction to'the county health department of the county
where constructed. 1 '
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ! Revised 2-22-2016