GW1-2022-03178_Well Construction - GW1_20220307

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WF WNSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name <d I lJ R YT fL 3
2080-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING`for multFca3ed wells OR'GINER;if a '4cabte
Aqua Drill, Inc. FROM To DIAMETER THICKNESS MATRRfAi.
Company Name Ivy 2 — D ft. �� io. ShJZ�t
7 16:itNNER CASING OR TUBING''`eothermal dosed-loo
2.Well Construction Permit#:o �Q C� / " FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. IL In.
3.Well Use(check well use): ft, ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural [)Municipal/Public ft• it. in.
Geothermal(Heating/Cooling Supply) esldential Water Supply(single) fL ft. in.
Industrial/Commercial " DResidential Water Supply(shared)
I&GROUT.--;
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft Q It- C/�.
Monitorin g pRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
;19 SAND/GRAVEL PACK if a' 11cable
_:Agtrifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EM PLACEMENT MET ROD
Aquifer Test E3Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) [3Tracer :.20tDRILLUVG_LOG:attach additional sheets if necessa
FROM TO DESCRIPTION color,hardness,wWrock e, rain size,etc.
Geothermal satin Coolin Return Other(explain under#21 Remarks) ft, ft- rr—d C
m y
4.Date Well(s)Completed: 2 -z 2 _11—Well ID# `/9 ft' VQ ft• 54 kJ d I ZOG
5a.Well Location: �s 6 ft- S �J r rC4-, -,4
ft. ft.
pprnwD
�Faaciliitty/Owner,Name�e/ C < L Facility ID#(if applicable) ft. ft.
/✓ a /a / L A4ez, J T z�j� bolo ,j ft. f4
Physical Address,City,and Zip
ft. ft
21:REMARKS:
su► I��a IZ d �,-
County Parccl Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.C ertitiead
N W ." . 2 _22
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6.Is(are)the well(srmanent or Temporary Signature of Certified Well Contractor Date
tT By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
►fthis is a repair,fill out known well construction information 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: 2 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2Q1001 construction to the following:
10.Static water level below top of casing: -30 (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: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
J above,also submit one copy of this form within 30 days of completion of well
12,Well construction method: 11Z C i l'I construction to the following:
(Le.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 276994636
13a.Yield(gpm) Method of test: 24c.For Water Suyyly&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: Amount: 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
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