GW1-2022-08897_Well Construction - GW1_20220912

WELL CONSTRUCTION RECORD(GW 1) Print Form
For Internal U - '
I.Well Contractor Information: se Only:
Chris King
Well Contractor Name 14.WATER ZONES
FROM TO DESCRiP1TON
2080-A OfL zl IL �0
r
NC Well Contractor Ccrtificatio W.ber fr• ft.
Aqua Drill, Inc. I5.OUTER CASING for multi-cased, ails OR LINER tfa licable
FROM TO DL4NCETER THICKNESS MATERIAL
Company Name ) fr- S5— ft /Ile, in
_O� C� /tz( l/ J�i
2.Well Construction Permit#: � o 76.INNER CASDVGOR TUBING(eothermal closedaao
List all applicable well conshuction permrys e.II#C,Connh;Slat&Irarimtce,etc) FROM ftTO DIAMETER THICKNESS MATERIAL ;
fL in. t
3.Well Use(check well use): ft ft in
water Supply wen: I7_SCREEN
Agricultural E)MmticipaUPublic FROM TO DIAMETER SLOTSrZE TmCKNF,ss MATERIAL
R
Geothermal(mmerci/Cooling Supply) fr• im t
Industrial/CommercialResidential Water Supply(single) fLfr• �.
Residential Water Supply(shared)
hmi lion 18..GROUT
Non-Water SD FROM - To MATERIAL HDIPLACEbiENT METHOD&AMOUAT
PPl1'Well: 2���
' D � e�.
.. Monitoring ;`Recovery � I✓Cs'+I'IIYU�ir C
Injection Well: ft ft.
Aquifer Recharge DCiroundwater Remediation D fr•
Aquifer Storage and Recovery D$aly Ber 19.SAND/GRAVEL PACK if a lleable
Aquifer Test FROM TO aIwTERIAL FdMrPLACEMERT MECROD
E)StormwaterDtainage fL ft
Experimental Technology Subsidence Control
fL ft
Geothermal(Closed Loop) Tracer
20_DRI LLING LOG attach additional sheets if necess
Geothermal(Aeating/Cooling Return) Other( lain under#21 Remarks) °nr TO DESCRIPTION(color,6
fL ard�s,suiUtvdr a sirx,tom)
d 4.Date Wall(s)Completed•1 Well ID# ft ft
5a.Well Location: fL fr 5
ft fr.
Facility/Ot<ner ate Facility W#(if applicable) ft ft
510 1"fa-M 1z,-1 ft ft
Physical Address,City,and Zip it ,
+
1 lty 11/�C� 2LREMARKS A. l �4 6d
County Parcel Identification No.(FIAT) 20
5b.Latitude and longitude in degmes/minutes/seconds or decimal degrees:(if well field,one lat/iong is sufficient)
22.Ce i
✓
W 1 ,Xb �J
6.Is(are)the wells ermanent or (OTemporary —auatum of Certified well Con —!for '3
Date
Yes or�No gY sl8nint;this jonn,I hereby cetiijl,that the rr211(8)was(were)constructed in occordance
7•TS this a repair in an erdsting well;
lfthis is a repair,fr11 out known well construction information mrd exp[aln tJte nature ojthe COPY ojthiswith 15A CrecardZhas01been prat vided to the?11 owner.C. 0 �1�ncoon Standards and that a
repair under#21 remarks section or on the back ofthis form.
8.For Geoprobe/DP 1 or Closed-Loop23•Site diagram or additional well details:
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-1 is needed Indicate TOTAL NUMBER of wells
drilled: construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: 50
__-_1 �M4STRUCTIONS
24aFor multiple wells list all depths ijdrfferew(example-3Q200'and 2Q1001 (�) con For AR Wens: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: .3 Q
#'water level is above casing,use-+- 00 Division of Water Resources,Information Processing Unit,
11.Borehole diameter: 1617 Mail Service Center,Raleigh,NC 27699-1617
ram) 24b.For Infection Wens: In addition'to sending the form to the address in 24a
12.Well construction method: B-i,l ( -)l � , above,also submit one copy Of this form within 30 days of completion of well
0-auger,rotary,cable,direct trust,ems) construction to the following.
EUIPLY WELLS ONLY. Division of Water Resources,Underground Injection Control Program,
/IQ1636 Mn1 Service Center,Raleigh,NC 27699-1636
e� thod of test 5 n � 24c.For Water Sunnly&Injectionthe ad Wll: In addition to sendmg the form to
pe:_ Q Z dress(es) above, also submit one copy of this form within 30 days of
Amonnt completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina De
partment of EuvimntrimW Quality-Division of Water Resources
Revised 2-22 2016