GW1--06353_Well Construction - GW1_20241025

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1
1.Well Contractor information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A � S'-7 ft. I (-1ft. rt. /
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap &cable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
CoCompany Name ft. l 3 ft. 6/9'in. / // (/
V Ve11 Li16.INNER CASINC.ORTUBING(geothermal closed-loop) `
2.Well Construction Permit#:5 l9e,)e!/ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County,State Un lance,eta.) 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 IMunicipal/Public ft. ft. 'in.
Geothermal(Heating/Cooling Supply) Mesidential Water Supply(single) ft ft. in.
industrial/Commercial 0Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 6 ft. Beal>}i'A/ c 61.;rS
Monitoring fRecovcry ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier - FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IDStormwater Drainage ft. ft.
Experimental Technology fOSubsidence Control ft. ft.
Geothermal(Closed Loop) ©ITracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) [;Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type grain size.etc.)
0 rt. 6 ft. 4 QA QS tA'/
4.Date Well(s)Completed:/0 --/c f -2 qWell ID# /_ fa 20 ft. 5i4N d e ode5a.Well Location: 30 ft. 3,25"ft. 13 i J a 6-(ZW(19r}C..
Kt°I ti 61 ,tit wl.°KJ 5 ft. ft. t" -.._ ,_. „r. ." s-";--.
Facility/O ncrName Facility IDS(if applicable) ft. ft. ``" ..°if...."..-'a :e'5...%.,,-'t
332 0 5 NiC (l ! 6g.0(itital ft. ft. n r T c) 21174
Physicalft. ft.
� Address.City.and Zip
j /i's' ! 11 PIP IC_C P` 21.REMARKS
It1:J, ,.r,`;
�i i
County Parcel Identification No.(PIN) '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
N W
IOTemporary Signature of Cc ific well Contra or Dote
6.Is(are)the well(s)EfRermanent or
By signing this from,I hereby certth that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or Eft1No will,ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill ottt known well construction information and captain the nature of the copy of this record has been provided to the well owner.
repair tinder#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 INSTRUCTIONS
• 9.Total well depth below land surface: -3� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd(erent(example-3E000'and 2@l005 construction to the following:
10.Static water level below top of casing: 3 0 (ft.) Division of Water Resources,Information Processing Unit,
ifwnter level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: in addition to sending the form to the address in 24a
d above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: `�)i t )Zi 1 1 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) J Method of test: %C;-r� 24c.For Water Supply&Iniection Wells: In addition to sending the form to
i- the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: d r f, Amount: 14' o'z completion of well construction to Ithe 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