GW1-2022-08998_Well Construction - GW1_20220923

WELL CONSTRUCTION RECORD(GW-1) Print Form
For Internal Us,;Only:
1.Well contractor information:
Chris King
well Contractor Name WATER ZONES
FROM TO DESCRIPTION
k—
30
ft.
15-0ErrERCASlNG rmuhkasedwelbiORLINERCifapllicablE�
Aqua Drill, Inc. SEP 2 :tl� 2@22 FROM TO DIAMMETER THICKNM
Company Name MATERIALin.
nN h/
2-Well construction Permit#: 16-HYNER CASING oR' uBluffit; eothermal closed-lea
List all applicable well ca,,,,m,,1on FROM TO DIAMETER ell wnstruction ......... ........ only, Parlance,dc,) ft. ft i in. THICKNESS MATERIAL
3-Well Use(check well use): ft. itt in.
SupplyWater We A: SCREEN17.
3Agrictilttanl E]Mulli-iP-I/Public DIAMETERFROM SLOT ME THICKNESSMATERIAL
3Ge.therMal(Heating(Cooling Supply)OOResidential Water Supply(single) in.
DIndustrial/Commerciai
Tni tion DResidential Water Supply(shared) 1&GROU
Permits#e UIC,GO ty,State,
'M n
---"-:W
NOD-Water Supply ON TO MATERIAL EMPLACnrwE..,,s- -011&AMOUNT
0 fL ft. -7�
Monitoring Dltecow.,v 11 .1 Lk f 12,5
Injection Well:... ft. —
J
ce
Aquifer Recharge DGound..ter Rentediati.. %
Aquifer Storage and Recovery DS-linity Barrier 19.SANDIGRAVEL PACK a li,,bl
.rAquifer Test ElStOraiwaterDrainage 0r*1 ft. TO ft. MATERIAL EMPLACEMENT METHOD
:_]Experimental Technology E3Subsidence Control ft. IL
E]Geothermal(Closed Loop) OTMM 20-DRILLINGLOG attach additional sheets ifnecessairy)
Ge lermal eafing(Coohng!wum) nOther lain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soilfrack
ft e, a size,ere.)
4.Date Wells) -
Completed: -2-� . ft. Kee � C
5a-Well Location: 12C_Well W# 3 IL 1;4
_56tud IZ-OCIC
�2 & ft. iZAK14C
Faciii ��ame ��
er cl Facility 1D#(if-Mliciffile) ft. ft
, W Ary & &
Physical Address,City,and Zip ft. fL
21-REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds Or decimal degrees:
(if1wlt field,one lamong is sufficient)
27-Certification:
inp.ra,y ­s­Ot Certified well U011tr4t0 r
6.Ware)the wea(loPermanent or Temporary -12-
Date
16Y79 5,7-Is this a repair to an existing well: []Yes orEINO wi s18nhth 15A NCAC 02C.0100 or this form.I hereby 1 eertjl5A N that CAC the wel10)was(were)constructed accordance
If this
is-repair,flit out known well construction bEformation and erplain the nature ofthe COPY ofthis record has been provided to the we 2C 0 -0200 Well ConstructionConstructionStandard,and that a
repair-der#21—ark'section or on the back ofth&f.,,,,. ll owner
23-Site diagram or additional well details:
8.For Cxeoprobe/DPT or Closed-Loop Geothermal Wells
on I ]raying 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 ofWells construction details, You may also attach ch additional pages ifnecessary.
9.Total well depth below land surface: INSTRUCTIONS
For multiple wells list all depths irdiffirat -3@200'and2@1003 (ft24a-For Wells: Submit this form within 30 days of completion of well
10-Static water level below top of casing: construction to the following:
Ywater level is above casing,u,,­+- (L) Division of Water Resources',Information Processing link
1617 AM Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. Cry)
24b.JL.��: In addition�to sending the form to the
12-Well construction method: Ar above,also submit one co address in._,4a
(Le-auger,rotary,cable,direct push, M.) copy Of this fOi7n within 30 days of completion of well
Construction to the following:
FOR WATER SUPPLY WELLS ONLY Division of Water Resources,Umlerl�groimd Injection Control Program,
1636 Nhil Service center,Raleigh,NC 27699-1636
13a.Yield(gpm)
Method of: Injection
Method of test 24c.For Witter Rvrnply A,Y­
sm on t
13b.Disinfection tvn.. A-f-1-1 ma the ildurcsstes) above, also submit In addition to sending the form to
�Amoutnt. I�Y_ 0 1z_ One copy Of this form within 30 days of
completion Of well construction to the:
where constructed county health department of the county
Form GW-1 North Carolina Dcpatiment ofE_iro_Ud Quitfity-Division of Water Resources Revised 2-222016