GW1--05985_Well Construction - GW1_20241009

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: ;
1.Well Contractor Information: •
Chris King 14.WATER ZONES '
Well Contractor Name FROM TO DESCRIPTION
2080-A 110 it. III it• 10.. &I P;rvi
12O ft. )A 9 fL C a i Pi Y+i
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licab�le)
Aqua aan Drill,e Inc. FROM R. I TO 6 ft.
I l/DIAMETER rry I i l rE MATERIAL6P hi'
Company `q� (
C 16.INNER CASING OR TUBING(geothermal closed-loop)-
2.Well Construction Permit#:5 � � ^S® e et T `, 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
Agricultural FROM TO DIAMETER SLOT SiZE THICKNESS MATERIAL
OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared)
IS.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT—
Non-Water Supply Well: 0 ft r y® ft. 1.0
�c 1 S Monitoring DRewvcry ft. ft
Injection Well: -
Aquifer Recharge OGroundwater Remediation ft. ft.
Aquifer Storage and Recovery Salini Barrier 19.SAND/GRAVEL,PACK(if applicable). '
ty FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
ExperimentaliTechnology l0Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary).
Geothermal(Heating/CoolingRetum) o� Other(explain under#21 Remarks) FROM fL TO, R DESCRIPTION(color,hardness,soil/rack type,grain site,etc.)
4.Date Well(s)Completed:10 "I ,29 Well ID# /A it. _®3 6 ft. 4i 1i cti KO L
5a Well Location: f 4�
2. ft. i t •—ft- iIv c 6-/-4)4 v i) t
ft. ft
Facility/Owner Na�m ft.
7e FacilityiD#(ifapplicable) ft.
1LIIgq .IZ.eAdI`U e_ - ft. ft. `-- ` � ;.. . .
•
Physical Address.City,and Zip ft. '.._
A isl g/hiC _ip 21.REMARKS - (I(_ i i) i/ /11/4
County Parcel Identification No.(PIN)
11..1n:47: .i:f i':'7r-li•e:-.)f.; tJ/.5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lat/long is sufficient) L"': "_,_'
22.Certific 'on:
N W -
6.Is(are)the well(s)gBermanent or IDTemporary Si nun of Certified Well Contractor Date
By signing this form,I hereby cert fi'that the nrll(s)was(were)constructed In accordance 1
7.Is this a repair to an existing well: DYes or ONo with ISA NCAC 02C.0100 nr 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 alike copy ofthis record has been provided to the reel!owner.
repair under#21 remarks section or on the back of this font.
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 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: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iifdifferent(example-3®200'and 2®1001
� construction to the following:
10.Static water level below top of casing: 7'' 0 (ft.) Division of Water Resources,Information Processing Unit,
If mates level is above casing,use"+"/ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (�e� (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: t I fi 1 above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,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) I C Method of test: J i q 1 14 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
ii-
13b.Disinfection type: 'T(l Amount: 16 6 2- completion of well construction to the county health department of the county
where constructed.
1
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources; Revised 2-22-2016