GW1-2022-04739_Well Construction - GW1_20220510

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CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
FROM TO IDFSCWMON
Well Contractor Name 'L 36
t 2080-A Cl 1
f fL
NC Well Contractor Certification Number 15.OUTER CASING for multi�ased webs OR LIlVER da livable
Aqua Drill, Inc. FROM TO 'DIAMETEx THICKNESS MATR'Rrfasr.
& �Q It. in. 45 Piz i V !C
Company Name 1
i q )1 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: / l — f7�- �1� FROM I TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(La UIC,County,State,Variance,etc.) D• ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM I TO I DIAMETER_l SLOT SIZE I THICKNESS I MATERIAL
i Agricultural OMtmicipal/Public ft. I % in
Geothermal(Heating/Cooling Supply) dResidentitd Water Supply(single) rL I fL in.
Industrial/Commercial DResidential Water Supply(shared) 18:'GROUT
_ Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well ft. ° J ft.
Monitoring ORecovery ft. ft
Injection Well: ft. ft.
Aquifer Recharge [3Groundwater Remediation
19.SAND/GRAVEL PACK ifs livable
Aquifer Storage and Recovery OSalinity Barrier FROM I To I IMATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. fL
Geothermal(Closed Loop) [3Tracer 20.=DRILLING LOG attach:additional sheets If.necessary)
'
Geothermal(HeatingtCooling Return) ther(expl
ain under#21 Remarks) FROM To DESCRIPTION(color hardness,wafroek type,grain size,etc.)
ft. rt Ae d t'2' )
4.Date Well(s)Completed: 2 qq-Well ED# ft. fL C e C IL-
5a.Well Location: J r J l U fZ r
ft. ft.
Facility/Owner Name Facility lD#(if applicable) fL L
�, •_�a ��Fj�.S�� ��)�, SJ1'�'ll'rtL��Z�'Lt�� �� ® 2022
Physical Address,City,and Zip 2`7 ft ft
My I
(�(j lt -rj 1Z al 21.REWARKfi - _
u fly
County Parcel Identification No.(PM)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees.
(if well field,one lat/long is sufficient) 22.Certification:
N rl, �_
6.Is are the well(s)6trmanent or OTemporary Signanrte oftertiffed Well Contractof Date
By signing this form,I hereby certify that the wells)was(were)constructed m accordance
7.Is this a repair to an existing well: [3Yes or PTo with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out!mown 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 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: ` SUBNHTTAL INSTRUCTIONS
9.Total well depth below land surface: J 6,5— (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: � (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: (m.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
n; 6(�l I above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: '9 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) .20 Method of test: ( 1 _ 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: /7! ! Amount:.J - 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