GW1--06446_Well Construction - GW1_20241101

1
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: •
1.Well Contractor Information: I
Chris King
14,WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A 5--5- ft. S 7 ft. 15-
S G 11., r)
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�t
© . tr ft ft. 6 in. /J 6,4 I id
Company Name I p� lf� �� t/ � v
�� �� `� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County.State,Variance.etc.) ft. H. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) re,iI•esidential Water Supply(single) ft. ft. in.
industrial/Commercial ®i Residential Water Supply(shared) 18,GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it. ( it. t 110-e e�`j 1)s
Monitoring 0Recovery ft. ft. f Cr
Injection Well:
ft. ft.
Aquifer Recharge D Groundwater Remediation
Aquifer Storage and Recovery {�Salim Barrier 19.SAND/GRAVEL PACK(if applicable).
LJ tY FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) i Tracer 20.DRILLING LOG(attach additional sheets if necessary) '
Geothermal(i-leating!Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(rotor,hardness soil/rock type,grain size.etc l
0 ft. / ft. 50 I I
'r
4.Date Well(s)Completed: )in ;la.2 4Well iD# ft. :3.5 ft. 5 to ryf C I /'�
5a.Well Location: ?St. (r ft k�rfI Je &AAA)j 4e
ft. f1.
J eg;iti c /10,1 e 5 t._-..o- T- _-
Facility/Owner Natnc Facility iD#(if applicable) , ft. ft. b ti,,.K4 , a a yi y:.
S6Slq its pI•C 6,2 14(.4i ft. ft. NOV j 7 ��±
Physical Address,City,and Zip ft. ft. _ L U 2-4.
4/AM I`�C 21.REMARKS r'•.'r�=.,r.-.� 3-
County Parcel Identification No.(PIN) �;��
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N Ci
I W
6.Is(are)the wells ermanent or Temporary Signature of Certified Well Cictor Da _ -�
By signing this form,i hereby cer4/%'that the iell(s),ins(were)constructed in accordance
7.Is this a repair to an existing well: DYes or LINO with!SA 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 glare copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back u f this forM.
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 MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths?I-different(example-3@2200'and 20r@100') construction to the following:
-gi
10.Static water level below top of casing: ...1 is-' (ft.) Division of Water Resources,information Processing Unit,
If water level is above casing,use"-I-- i 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
A��Z �� 1 I above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Ct i / construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) I - ow g'
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° Method of test: S 1Q f t,�1'j' 24c.For Water Supply&iniection 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: )Li "H Amount:)2, a-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