GW1--06351_Well Construction - GW1_20241025

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name ��FnnROM TO DESCRIPTION2080-A `JO ILga••) R. /Q :at!il
CI t t1
NC Well Contractor Certification Number )3o f t :J�i /© '�i o Pi M
15.OUTER CASING(for multi-cased wells)OR LINER(If ap likable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS 1 MATERIAL
s
ft. •-�J1 ft. / in. e �l 1 V
CompanyName ®V (�j/� 1/
�� r ( ( I ,INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:'Ss3 CtCj1I e 1/ . rL 1 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
ft.
ft.
DIAMETER SLOT SIZE THICKNESS MATERIAL
AgriculturalMunicipaVPublic ft. in.
in.
Geothermal(Heating/Cooling Supply) 171,11:,sidential Water Supply(single)
rt.tndustriaUCommercial 0Rcsidential Water Supply(shared)
1&GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: - © ft. �� ft. Bed N4�j4c C. �;p S
t
DMonitoring 0Recovery ft. ft. -
Injection Well:
Aft.Recharge ft. ft.Remediation
Aquifer Storage and Recovery19.SAND/GRAVEL PACK(If applicable) _
A
q g 0SalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
0Aquifer Test DStormwater Drainage ft. ft.
DExperimental Technology I0Subsidence Control ft. ft.
DGeothermal(Closed Loop) (Tracer
20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling.Return) [(Other(explain under#21 Remarks) FROM TO DESCRIPTION(�olor,�h/a�rdness soillrock t pe Train size etc.)
`j C0 ft. / ft. /Zed C I/'1 y
4.Date Well(s)Completed:10'"I R'I—2 -I Well ID# /S ft• 60 R. 5 ev d.( /Z C t
5a.Well Location: 60 n. i%S-ft. 3 a ,c M1 &i•.Z u isiC
• ft. t�,? ft. ky ll,.n t 7,/y`' a 7l'::-,1
Facility/Owner Name Facility ID#(if applicable)
ft. ft. l'�PI
f ZUZ4 53`I �d 5 A l er"1 On.ri _ /Art C 7J 1714Vll
Physical Address,City,and Zip ft. ft. 9 r
Al P'f Mir;e21.REMARKS
County Parcel Identification No.(PIN) ^- r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lat/long is sufficient) 22.Cert ca'on: _
N W - V —;71
6.Is(are)the well(s)`A 'ermanent or 0Temporary Signa urc of Certified well Contractgtr pace
By signing this Arm,I hereby cerg,that the null(s)awe(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or EgNo 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 it formation 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
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: v ' (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@100') construction to the following:
7
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
s
11.Borehole diameter: K� (in.) 24b.For Infection 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: ri I j�- drz:11 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) a o Method of test:73 i et h 4- 24c.For Water Supply&Injection Wells: In addition to sending the form to
®q+� (� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: R'i r! ' Amount:) 61 in .z 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 Revised 2-22-2016