GW1-2022-09813_Well Construction - GW1_20221027

WELL CONSTRUCTION RECORD GW 1 Print Form
1.Well Contractor Information: For Intemal Use Only:
Chris King
We11 ContractorName 14.WATER 7AIVES
2080-A FROM TO, DESCRIPTION .
ft NC Well Contractor Certification Number ft ft
Aqua Drill, Inc. 1s.OUTER CASING.fo
FROM TO DM
rmEAsedwells ORLiNER da 'licabie
Company Name rAETER Tft. HICKNESS &M.TERIAL
2.Well Construction Permit#: ° J�/v�- / R / 16•INNER CASING OR TUBING -List all applicable xr[t wrrstruction permits r e (/L �`''� v �� FRODi TO eothermal closed-loo
( C Cozen%State•YarlarrcQ etc ft. DIAM1D:TER THICKNESS ,MATERIAL
3.Well Use(checkwell use): �
Water Su I ft ft in
PP Y Well:
17.SCREEN
Agricultural
MunicipalfPubtic FRO1%i TO DIAMETER _SLOTSIZE THI Geothermal(Heating/COolin Supply) fr it in CrnvEss M1iATERwL
g dential Water Supply(single)Industrial/Commernial DResidential Water Supply(shazed) in.
h1i lion iB..GR0
Non-Water Supply We11: FROM TO MATERL4T.Monitoring ft EM1iPLACE6H NT METHOD&AMOUNT
Injection We1L• DRecovery t Jtli1C
ft ft PS
Aquifer Recharge p� ft. ft
T�Gruundwater Remediation
Aquifer Storage and Recovery Salmi B 19:SAND/GRAVEL PACK da licable
ty ��Aquifer Test E)StormwaterDrabtage FROM TO 51ATERIAL En4PLAC
Experimental Technology ft Ey1pRTyrETFfOn
Geothermal Closed Subsidence Control
( Loop) ft
OTIaCer 20.DRILLING LOG attach additional sheets ifnec
Geothermal(Heating/Cooliug Baum
) Other(explain under#21 Remarks) FRont To DEscrt>PrroN w►or,nardaess,soluractt
4.Date Well(s)Completed��- 1^ ft ft taro 5tze eta
Well ID# ft
e. .
Sa.Well Location: �
R: 5T h• ° Q
kju
Facility/Owner Nome fL ft
Facility 10#(ifapplicable) R. - /�� s
ft rL
Physical Address.City,and Zip )
ft ft
County 2L REMAgifS
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: =- n
(ifwelt field,one lattlongis sutliciem)
N 22.Certificati
6.Is(are)the well(s)6ennianent or IOI. Temporary Signs of Certified Well Contra
7.Is this a repair to an existing well: DYes o Date
By signing this 02C I hereby cer[N That the xell(s)was(were)Ifthis is a repairfn out bzotvn well constnrctian information—rued o 'N�ISR NCAC 02C.0100 or ISr1 NCAC O2C.0200 JYeII Construeh'ant Stands�and that Q
repair under#2l remarkvsection or on the back of thirfarm. esplaur the nature ofilre cagy ofthis record has been provided to the well owner.
8.For Geoprobe/DPT or Closed Loo 23.Site diagram or additional well details:
construction,only 1 GW-1 is needed Ipn catehT Wells having the same YoR may use the back of this page to provide additional well site details or well
drilled: NUMBEROfwells construction details- youmayalsoattachadditional pa
ges ges ifnecessary.
9.Total well depth below land surface: S�MITTAL You
Formzdsifdiffernnt(erampl@200 and2@100) (fh)
24a.For Alt We
rip!ewellslkt all depth , Submit this fowl within 30 days of completion of well
10.Static water level below top of casing; �Q construction to the following:
jrvaterlevel is above casing.use••+ (fL) Division of Water Resources,Information Processing Unit,
11-Borehole diameter: 1617 Mail Service Center,Raleigh,fn•) gh,NC 27699-I6I7
12•Wen construction method: J 24b.For Inlech epS: addition to sending the form to the address in 24a
(r.e.au e,rotary, %7, above,also submit one copy of ft form within 30 days of completion of well
g Easy,cable,direct push,etc) construction to the following.
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
13a.yield(gpm) 1636 Mai!Service Center,Raleigh,NC 27699-1 tro Method of test:S( 1
636
24c For Water SuODIv&Infection Wells: In addition to sending the form to
136.Disinfection type:l�T� the addresses) above, also submit one copy of this form within 30 days of
Amount (? completion Of well construction to the
where constructed county bealth department of the county
Form GW-1
NOtth Carolina Department of Environmental Qn dity-Division of Water Resources
Revised 2 22-2016