GW1-2022-06476_Well Construction - GW1_20220621

,_ = Print Form
WELL CONSTRUCTION RECORD Q W-1) For Internal Use Only:
I
1.Well Contractor Information:
Chris King 14.WATER ZONES:.'
FROM TO DESCRIPTION
Well Contractor Name
2080-A
% ft.
NC Well Contractor Certification Number 15.OUTER'CASING for.multi-cmeid wells`ORLINER d a' Gcable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL /
ft. 6SJ� in. ,, g t!
CompanyNamc 16:INNER CASING'ORTUBING(geothermal closed400") T..
2.Well Construction Permit#: w e�r V^ FROM TO DIAdIE1ER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance eta) ft rt. in.
3.Well Use(check well use): it. ft m
Water Supply Well: FROM TO DTAMETER SLOT SIZE THICKNESS MATERIAL
gricultural DMunicipal/Public f. f, in
- Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft• in
-.- are
lndustrial/Commercial Residential Water Supply(shared)
=11crigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: clft 0 ft
Monitoring Recovery ft. ft.
Injection Well: ft. g,
Aquifer Recharge f�- Groundwater Remediation
19:SAND/GRAVELPACK'da licable
Aquifer Storage and Recovery �O'Salinity Barrier FROM To MATERIAL: EMPLACEMENT DiETEioD
Aquifer Test DStomlwater Drainage
Experimental Technology 0 Subsidence Control ft. tt
Geothermal(Closed Loop) [ITracer 20:DRILLING LOG attach additional.sheets if necessa ).
FROM TO DESCRIPTION color,hardness,wil/mIk e, is size,etc.
lGeothermal(Heating/Cooling Return.) nOther(explain under#21 Remarks) ® ft C e d CIO
4.Date Well(s)Completed• `3" 1 -d_ Well ID# h o � 41 6 (o n" j ft ;5iqN d jeer-
.e t
5a.Well Location: cs 5 e
fL %
Facility/Owner Name Facility ED#(ifapplicable) ft ftA_ K10_aN0dJr_
,
Coy ~
Physical Address,City,and Zip ft. ft. -
11 14 21: ^'REh1ARKS
coup ParcelldentificationNo.(PIN) ,o
tY
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(ifwell field,one 1at/3orrg is sufficient) 22.Certifica on: V ;sou t;lL"r l i
N W e .�l '4Y_
ermanent or Tem ora Signature of Certified WellCo�tor Date
6.Is(are)the well(s) 1p � p ry
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.is this a repair to an eidsting well: E]Yes or E]No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
lfthis 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 GW-1 is needed. Indicate TOTAL NUMBER Of wells construction details. You.may also attach additional pages if necessary.
drilled. ) S� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ! t l (th) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@@2000'f'and 2@100) construction to the following.
10.Static water level below top of casing: ., C 2 (ft) Division of Water Resources,Information Processing Unit,
If wafer level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
� y above,also submit one copy of this form within 30 days of completion of well
12.Well Construction method: r o& 1 I construction to the following.
(Le.auge,rotary,cable,direct posh,elc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: �* 1636 Marl Service Center,Raleigh,NC 27699-1636
13a Yield(gpm) 0 Method of test: J is 24c.For Water Supply&Injection Wells: In addition to sending the form to
11 / the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type 7 Amount: Q 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