GW1--06560_Well Construction - GW1_20241101

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 7c ' -71-ft• 'z 61 rt/"l
ft. ft. j
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable).
Aqua Drill, Inc. FROM TO DIAMETER ; THICKN MATERIA///L
C) ft. L ft. 6//le 1 in. ,/cgs /'�/A J V
Company Name V
t/.''�q ` ' ` 77 /)� 16.INNER CASING OR TUBING.(geothermal closed loop)
2.Well Construction Permit#: l lam'e1 J� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Slate 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 EDMunicipal/Public ft. ft. in.
DGcothermal(Heating/Cooling Supply) {Zi•csidential Water Supply(single) R ft. in. '
0 Industrial/Commercial 0 Residential Watcr Supply(shared) 18.GROUT -
nirrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 451C) ft. i?� �j �,�i s
Monitoring
injection Well:
Recovery ft. ft. l�
ft. ft.
Aquifer Recharge DGrotmdwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness.snit/reek type,grain ,etc.)
Geothermal(Heating/Cooling Return) Other(explain under al Remarks) ft. 3 ft. 56
i
4.Date Well(s)Completed: JO -I q-A`Well 113# `17>� ft 30 ft' f;
S it)di ) IL L
5a.Well Location: 30 ft. C.5'ft. S1 ue G-�Ri - i
e ligef I 14 6 Al C$ ft. RJ ft. •
r Facility/Owner Name Facility lD#(if applicable) ft. ft.
36)c I'J N c C.,
n. ft. ' b- '- ' "r-,cm
Physical Address.City,and Zip ft. tt' pp n
. 21.REMARKS t�U v/ V = Ill/S.
County Parcel identification No.(PIN) I I r'`'1.)::- - --,-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: f i`i;, f
(if well field.one iat/long is sufficient) 22.Certiifi ation:N W e )111.......1.
)10 �(® -/% 42 4
6.Is(are)the well(i�ii'ermanent or Temporary Signature ofCcrti d Well Con Date
By signing this form,I hereby certii'that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or 011Zo with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and dzet a
If this is a repair,fill out known well construction infiirmation 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:
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 OW-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 if different(example-3@200'and 2@100') construction to the following:JJ
10.Static water level below top of casing: (0 D (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: Cra (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
" '' 1 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: d iz 1 i 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) ! ' Method of test: 3►!1i7 24c.For Water Supply&injection',Wells: In addition to sending the form to
II / j� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: /4 f !d Amount: 3Q 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