GW1--05882_Well Construction - GW1_20241001

WELL CONSTRUCTION RECORD (GW-1) For internal Use Only: I _ .
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRiIPTTION
2080-A 1 2 ft I 1 j ft I C' ( I Ili i�
��t1,ft. 3C ft. (..t fir
NC Well Contractor Certification Number �"`•- �
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
_ 16.INNER CASING OR TUBING(gggthermal closed-loop)
2.Well Construction Permit#�.,�, / -G-' 3y f FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,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 0MunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) Ef$,psidcntial Water Supply(single) ft. H, in7
Industrial/Conuncrcial 0Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: C ft. ')c, it. f"��,Ni.V11,. `11;e s
Monitoring ®Recovery ft. �e ft. jJ 11 r` i
Injection Well:
ft. ft.
Aquifer Recharge 0Groundwater Remediation
Aquifer Storage and Recovery Salini Barrier 19.SAND/GRAVEL PACK(if applicable)
ty FROM TO :MATERIAI. EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) EllTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,groin size,etc-)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) O ft ft. e]C �{ i ��
C 1
4.Date Well(s)Completed: f , !Well ID# /_ ft. II Q ft. 3 v. i d /Z�c C
Sa.Well Location: J II G ft. 32 5—ft. t$ U C:/ (�12 la hi I-j e.
ft. ft. V
Facility/Owner Name Facility lD#(if applicable) ft. ft.
..7
/l(-/ , l►witzrz- pg (I if\ kprI 14t11 "J ft. ft.
Physical Address,City,and Zip ft. ft. 1 I T s 7 1 r1 n
Oa_
n 21.REMARKS
County Parcel identification No.(PIN)
_7,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification:
A
6.Is(are)the wells) Permanent or Temporary Signature of Certified Well Contractor i" Date
Br signing this form.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or t o with iSA NCAC 02C 0100 or ISA NCAC 02C.0200 Well Construction Standards and that u
If this isa repair,.fill out known well construction inhumation 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 hack 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
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:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 25-
(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@200 and 2(d3100') construction to the following:
10.Static water level below top of casing: ‘ Q (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 Injection Wells: In addition 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: ig 1 f l Lx i I 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
13a.Yield(gpm) i/ c Method of test: 1 c k+ 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/ r/7/ Amount: I t 6 1- completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division°MWater Resources Revised 2-22-20lb