GW1-2021-01023_Well Construction - GW1_20210322

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WELL CONSTRUCTION RECORD (GW-1) For Internal Ilse Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
WellC rtrnctor Name FROM TO DESCRIPI'10
2080-A 7L 9 ;IoryN
fL ft.
NC Nell Contractor Certification Number IS.OUTER CASING for muI"Kaaal well, OR LINER ih lieahle
Aqua Drill, Inc. FROM TO DIAMEI f:R TIH('RNf:SS MATEHIAt.
ft. ft. IR
t'OlnpAn)NaITC
16.INNER CASING OR TUBING eo�ernlal rimed-too
2.N FROM'ell Construction Permit H: OM TO IiukwTER I THICKNESS MATERIAL
l.rn all apphcuhlr.r//onnrtrt,nam permrtc o e. f.7(',('mmn:Sraee in- <;�1 fL i
V /� I ill D
3.Well Ise(check well use): ft. ft. r
n.
Water Supply Well: 17.SCREEN
"ROM TO DIAMETER SLAT SIZE THICKNESS a1:ATERIAL
Aencultural �Municipal'Public R. fc m
Geothermal(Hcaling'Coohng Supph) Residential Water Suppl}'(single) ft ft in.
id Industrial/Commercial DResenual Water Supply(shared) 18.GROUT
Irrigation FROM to MATERIAL EMPLACEM ENT METHOD&AMri
Non-"ater Supply Well: ft. R.
-1monitortrp ORecovery ft. ft.
Injection Well:
h. ft.
Aquifer Recharge ❑Groundwater Remediation
19.SAND/GR PACK MA ble
Aquifer Storage and Recovers' Salinity Barrier FROM TO TO MATERIAL EMPLACEMENT MLT110D
Aquifer lest [3Stormwater Drainage f. ft.
Experimental Technology Subsidence Control f. f.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(am b additional ahead ifessena
Geothermal(I leating/Cooling Return) MOther(explain under 421 Remarks) mom I To IDeSCRIPrION lrmra a,moa...,ivr.ek - v,,ec.l
J in.
ft.
1.Date Wells)Completed-2 — -2 I Well IDN h- R. _ _ C 1C
C5a.Well Location: ,/�
�o K 1 ; r' C� �/� ft. It.
"aa lin Ox ner Name I aoda,ID-I ifapplicable) h. re. -� �_I•�
P��h\\csical Address.C'it},and lip
ft. f4
4/n y(_"�•n d� 21.REMARKS
YIf V1A7�V I S
ounry Parcel Idandiwuon No I PIS I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
lifaeIl field,one lal/longis saffcien0 22.Certiftca If n:
6.Ishii the well(s erma nent or 1'1'emporary SiE eoTCeni ed Well Con actor Dalc
B .rx A tlr. Iona I h hs (h An h ,/IA) . I .i.....I /nrr
7.Is this a repair to an existing well Yes Or ah / l A(.I( 02( 0100 / d A('a( O ('.0100 W//C' r.,vmomn S'm /rnlr end rharo
1(1l r,r,a nlrvua III ale kno.n.ell n:ruennn injormaoorr Aerplaar the rrnrurc/rh. 'f9 /on, ha,h r pronA,1 ,(he.,It o.wer.
mpul.uuJrr 21 re mark,se.non...on the hunkaJlha/nnr.
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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You mar also attach additional pages ifnecessary.
drilled SC BMI"I'TAL INSTRUCTIONS
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
Fur mul/iple well,lrnl ull Aep(h.,fJg,,.,(umnple-'3/�"2/o�us''unrl lffelou'7 construction to the following.
10.Static water level below top of casing: rl lJ (ft.) Division of Water Resources,Information Processing 11nit,
If.,,,,levehs ahmve uu,rn¢,roe " 1617 Mail Service Center,Raleigh,:NC 27699-1617
11.Borehole diameter: (in.) 24b. For Imeclion 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
7
12.Well construction method: / 1 �( /✓IC \I construction to the folloumg
1 i e.auger.rotary'.cable,direct push.etc.I
Division of N'ater Resources.Inderground Injection Control Program,
FOR N'ATER SUPPLLII/N--ELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 7 699-1 636
13a.field(gram) Method or test: 24e For Water Supply & In iection Wells: In addition to sending the form to
I the addofs'S(as) above, also submit one copy of this form within 30 days of
136.Disinfection type:Hr(+ Amount: , completion of well construction to the county health department of the county
where constmcted.
Porn Gw-I Non[)Catolina Ikpartment of Environmental Quahry-Division of Water Resources Revised 2-22-2016