GW1-2022-10752_Well Construction - GW1_20221205

i _ - Prrit,rForm___
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: f
Chris King 14.WATER'ZONES
FROM TO DESCRIPTION OC
Wc11CoMmctbrName
2080-A
- ft.
NC Well Contractor CertifitxtianNumber ,15..OUTER CASING for mul' ed'wells OR LINER Of ann'cable
Aqua Drill, Inc. FROM I TO DIAMETER i THICKNESS I MATERIAL p. i
Company Name _ Y
I6.71NNER CASING OR TUBING eothermal closed loo
2.Well Construction Permit#:
,,�I FROM TO DLAAMER` THICKNESS MATERIAL
!✓. � � L-6�
List all applicable well construction pr9n:0(tZ U� ouno,,State,variance,etc.) ft l°'
3.Well Use(checkwell use): fr. ft. in
Water Su Well: 17.SCREEN -
Supply FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipaMblic ft % in.
Geothermal(Heating/Cooling Supply) MReidentitil Water Supply(single) fL ft in.
Industrial/Commercial 011esident.i.1 Water Supply(shared) -4 GROUT.
lIrioation FROM TO ERNL EhiP EMENT hIETH D&AMOiJNT
r 01
Non-Water Supply Well: ft' ZC�
Monitoring r-Recovery ft. ft.
Injection Well: ft. ft.
Y. Aquifer Recharge 013roundwater Remediation
19+SAND/GRAVEL PACK.if applicable)
__ Aquifer Storage and Recovery E3Salinity Barrier FROM To MATERIAL lKMPLACEMEAT METHOD
Aquifer Test OStormwater Drainage ft. ft
Experimental Technology OSubsidence Control ft fL
Geothermal(Closed Loop) OTracer ••20-DRILLING LOG attachadditionafsheetsif needs -..: ,
Geothermal(Heating/Cooling Return) .r Other(explainunder#21 Remarks) FROM TO DFSCRWn colon hardness soatrock type,P,ain 31m.etc.
IL ft
4.Date Well(s)Completed: _ Well ID# ft
5a.Well Location: ` P
ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft
ft ft i = r—p
Physical Address,Cit};and Zip I �i� � °� +r} ff ft R
/ (Y t fi/ r
y� ` q u
A`t/ p1'k 4A C 21 REMARKS
ounty Parcel Identification No.(PIN) "krr �'"° i
OG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: dW=
(if well field,one lat/long is sufficient d 22.Certification: N
< S� Nam!'. `Iii`7 W
6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified Well Contractor i Date
By signing this form,r hereby certify lhot the wells)was(were)constructed in accordance
7.Is this a repair t0 an existing well: E3Yes or E)No with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Wdl Construction Standards and that a
If this is a repair,fill out Imown well construction information and explain the nature of the copy of this record has been provided to the;well owner.
repair under#21 remarkr section or on the back of thisform. 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 24M For All Wells: Submit this form within 30 days o f completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@1001 construction to the following'
' I,
10.Static water level below top of casing: 4;t l3 (fit) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: TC /7F construction to the following.
(Le.auger,rotary,cable,direct push,etc.) I.
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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1
13a.Yield(gp ) -� � Method of test 24a For Water SuuDiv&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount �,�'� 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 i Revised 2-22-2016