GW1-2022-00231_Well Construction - GW1_20221216

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Chris King
14.WATER ZONES.
Well ContractorName FROM TO ---F—IDESCRIPTION
2080-A eft. ft fl-I
ft. ft.
NC Well Contractor Certification Number
15.OUTEXCASING(for Tjt��ased
E� s,PL=ifapillcable)
Aqua Drill, Inc. T M MATERIAL
Company Name 1519221 1 Ifs) 6
.1HTNER , INGUR G(ae6therifial.closed400p)
2 Well Construction Permit (15 7 FROM TO — DUMETER I THICKNESS MATERIAL
List all applicable well construction permits(te UIC,County State,Variance,c1r) fL ft. to.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 47.SCREEN
FROM TO DIAMETER SLOTSTZE THICKNESS MATERIAL
JAgricultuml DMimicipal/Public fL it. in.
nGeothermal(Heating/Cooling Supply) ffResidential Water Supply(single) ft.
ft. in
:)Industrial/Conmigrejal EIResidential Water Supply(shared) 18.1 GROUT
11nigation.
Non-Water Supply Well: FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Monitoring
pRecovery ft. ft.
Injection Well:
Mot" ft. ft.
f''t'-
Aquifer Recharge DGrouridwater Remediation
19'.SANDDIGG RAVEL PACK(if-applicAlA
DAquifer Storage and Recovery OSalinity Barrier
rRobt To I I%IATFRrAy- I �PIACEM�ENTNIUMOD
DAquiferTest oStormwater Drainage ft
-:1Experimental Technology OSb.id.Control It.
&
RGeothermal(Closed Loop) OTracer P10fflOING., OG,(attacWadditi6"lkheetsifiiecessiryl.,,-.:-''-"'-,I
220therinal(HeatingiCoOling Return) M- Other(explain under#21 Remarks) FROM I TO ft. I DESCRIPTION f-for.hardness,so1Vf0&t3?P%grain sir,ere
.1 )
11 (n ". I
4.Date Well(s)Completed-/_ -jiL_:-:.,/Z—Well ID#
fts c1f (3
5a.Well Location: e, 47,z
ft. ft. i
Facility/Owner Name Facility IDN(ifapplicabk) M ft r
133 1DQ0AK1, 1 ft &
V F_�L)
PAh 'cal Address,City,and Zip ft. ft.
'2L REMARKS
PEP i 4 2029
County Parcel rdentification.No.(PIN)
Unit
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 5AhQ'7j OG
(ffwcU field,one Wong is sufficient) 22.Certification:
N w 2
6.Is(are)the welt(s)EIP-11—nent or oTemporary Signature ofCerdfibd Well Contractor_', Date
By signing this form,I hereby cerfifi,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well-. Dyes or No with ISANCACO2C.0100 or.15.4 NCAC:02i7moo well construction Standards I
';;;�cfion iqlbrinallon and explain the nature ofthe ZY Ofthis record has been provided to th I e well owner.
Ifthis is a repair,fill out lojov.7z 1;;l cc dr and that a
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8..For Gcoprobe/DPT or Closed-Loop Geothermal Wells having the same You mayuse the back of this page to provide additional well site details or well
construction,only I 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: 22, UP 24a.For All Wells: Submit this 'form within 30 days of completion of well
For multiple wells list all depths if'diffierent uple-3@200'and 2@100) construction to the following: i
10.Static water level below top of casing: 30 (fL) Division of Water Resources,Information Processing Unit,
Ywater level is above casing use 1617 Mail Service Ceiit6t,Raleigh,NC 27699-1617
11.Borehole diameter.- 6 —(--) 24b.For Iniection Wells: In addition:: to sending the form to the address in 24a
12.Well construction method:—14, above,also submit one copy of t1iis1f4rin within 30 days of completion of well
0-anger.-tam cable,direct pusb.etc-) construction to the following: I
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: + 24c.For Water Supply&Injection OVells: In addition to sending the form to
the address(es) above, also submit l'otie copy of this form within 30 days of
13b.Disinfection type: /V I t7 Amount. 1 d completion of well construction to the I county health department of the county
where constructed.
FcrmGW-1 Worth Carolina Department ofEnvironmentaI Quality-Division of Water Resources Revised 2-22-2016