GW1-2022-08997_Well Construction - GW1_20220923

WELL CONSTRUCTION RECORD(GW 1) nly: Print Form
For Internal U se O
1.Well Contractor Information:
Chris King
1i WATER zoNEs
Well Contractor Name FROM TO DESCRIPTION
NC Well Contractor Certification Number ( 1J ft ft
Aqua Drill, Inc. S F p ` (� 15.OUTER CASING for multi-eased wells OR LINER rf a licable
`, 2022 FROM TO DIAa"IETER THICKNESS MATERIAL
CompaayName V ft f R I- ��
f+� '"� ~r, "� y ' {1rg,+ 16.INNER CASING OR TUBING eothermat dosed-loo
2.Well Construction Permit#: ^'. , yam `/ J FROM To
List all applicable"ll construction permits#.e.UIC,Connh;State,Variance,etc) —' ft. DEN R TnrCKNEss MATERIAL
ft. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well11: 17.SCREEN
Agricultural FROaI TO AMLTFI SLOT SIZE THICKNESS MATERIAL
_ �MunicigaUPub(ic ft ft is
Geothermal(fieating(Cooling Supply) Residential Water Supply(single)
ftDi
�•
QlResidential Water Supply(slurred)
:' IITi fion 18.GROUT
Non-Water Supply Well: FRonI � ft
To MATERIAL EMPLACEMENT METHOD&MIOUNT
�} O
Monitoring ' Recovery
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediaticm ft' th
Aquifer Storage and Recovery Salinity Barrier 19.SAND/GRAVEL PACK ifa lieabie
Aquifer Test FROM TO NTH AL EMPLACEMEnT METHOD
ElStormwaterArainage ft. ft
Experimental Technology oSubsidence Control
ft
Geothermal(Closed Loop) Tracer
20.DRILUNG LOG attach additional sheets if a
Geothermal(Heating/Cooling Retum Other( fain under#21 Remtui:s) FROM TO DESCRMIOx C ecessaolor hardy ess,safVrock n�,eta)
ft
4.Date Weil(s)Completed: -Well ID# cd C I
3 ILft. {vLt a ClC
Sa.Well Location: ft.. �
3 'uc tzwlv��C
ft. fL
Facility/Owner Name Facility ED#(ifapplieable) ft• ft
k rV ft. ft
Physical Address,City,and Zip ft.
ft.
�iiC a P21L_ MARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minuteslseconds or decimal degrees:
(ifwell field,one lavlongis sufficient)
22.Certification:
N .�
6.Is(are)the wells permanent or Temporary vI Srg rabrre of ----fled greIl Co for I .2L
Date
7.is this a repair to an existing well: Yes or Bp signing this form,I hereby eerth,that,the wells)was(were)constructed in accordance
Ifthis is a repair,fill out kaorwr well construction jormalion�esplain the nature ojthe ropy ivith I SA NreAcord has been provided N'C 02 11 20O d1 C.0100 a' anstrucbon Standards and that a
n.
repair under 021 remarks section or on the back ofthisfor o
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 l OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
9.Total well depth below land surface:__ Z SUBMITTAL INSTRUCTIONS
For multiple wells list all depths ifdiffer¢ra(¢rumple-9Q200'and 1QI00) (ft) 24a.For AIL Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing:
�6 construction to the following:
Yuuter level is above casing use'+^ (th) Division of Water Resources,Information processing Unit,
1617 Mail Service Center,Raleigh,NC 2 769 9-1 61 7
11.Borehole diameter. fn)
i 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction:method: j/Z C' i if! above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc.) construction to the following.
EDisinfection
PPLY WENS ONLY: Division of water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test`J1 �__
24e.For Water Su l &Infection Wells: In addition to sending the form to
ype:k-1-r--'---_ Amount 1 t7 Z the addr�es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnviromnental Quality-Division of Water Resources
Revised 2-22 2016