GW1-2022-10763_Well Construction - GW1_20221209

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: --
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
2080-A S6 ft. it UCS ,•�
it. ft.
NC Well Contractor Certification Number
IS.OUTER-CASING for mnllitased wells OR LINER if a licable
Aqua Drill, Inc. FROM To Drnrotrrrcn THrcravEss MATERIAL
Company Name ft-
ft. CP%_5/� t° a`tYc7 C 71-1A III
16.INNER CASING OR TUBING eothermal closed--llan /
2.Well Construction Permit#: aC fv FROM I TO DIAMETER I THICKNESS I AATERIAL
List all applicable well construction pumits(i.e.UIC,County,State,pariance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TRFC ESS MATERIAL
Agricultural �Municipal/Public ft- ft. in.
Geothermal(rnmer g/Cooling Supply) aitesidential Water Supply(single) ft, ft. in.
IndustriaUCommercial Residential Water Supply(shared) 18.GROUT
Ini ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non Water Supply Well: fr ft. r
Monitoring
�_ Recovery ft. ft. +U
Injection WRearge (ell:
ft.Aquifer chGroundwater Remediation fL
A uifer Storage 19.SAND/GRAVEL PACK ifa licable
q rage and Recovery Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStoro water Drainage ft. fL
Experimental Technology oSubsidence Control ft. fL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets H necessary)
Geothermal(Heating/Cooling Return) -Other(e lain under#21 Remarks) FROM I To ft. DESCRIPTION color hardness,soi0rock a m ra size,etc.
--77 ft.
4.Date Well(s)Completed: ' 2-.2 2-well ID# ft. ft
a Well LocationC:
ft. ft. f
Facility/Owner Name Facility ID#(if applicable) ft. ft
313 i rz �� ft. fL
Physical Address,City,and Zip 'lz 6 q ft. & { Ell A e�w
n/ � �' �s
21.REMARKS
County--�! Parcel Identification No.(PIN) 202Z
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Wii -a
(if well field,one]at/long is sufficient) t i
22.Certification:
6.Is(are)the well(s)jg Permanent or Temporary Signature ofCe ied eii n `or Date
`-� , + 8y signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or 1�3No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that o
If this is a repair,fill out btown well construction information/a'nndd explain the nature ofihe copy of this retard has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
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: 1 � (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Far,tnrltiple wells list all depths if tuff eni(example-3@200 and 2Q100 constriction to the following:
f'A ater level is above casing,use•+Static water level below top of casing:
If (ft.) Division of Water Resources,Information Processing Unit,
wf~ 1617 Mail Service Center,Raleigh,NC 27699-1617
I1.Borehole diameter: `� (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: %J/ d1z t ,1 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-
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
p 1636 Matz Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)_/ Method of test:�;SGi 24c.For Water Supply&Injection Wells: 1n addition to sending the form to
ry the addrrss(es) above, also submit;one copy of this form within 30 days of
13b.Disinfection type: r-H Amount: 9 (n C.� 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 Revised 2-22-2016