GW1-2023-00728_Well Construction - GW1_20230113

PrinYForm"
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name T"„ FROM TO DESCRIPTION
2080-A � t:. 6 -"� tie ft-
ft
NC Well Contractor Certification Number J A�HIV I 1 !� 2023
2 3 15.OUTER CASING for multi-cased wells OR LINER(if a livable
Aqua Drill, Inc. ` FROM TO DIAM$•TER
i TMCKNFSS MAT ER
ft MATE.
Name u"t r. + 16:INNER"CASING OR, ING teeothertnalclosed-loo
{ > /s 3, FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#k (_a� l�' 1iL
List all applicable well construction permits(ue.UIC,County,State,Variance,etc) ft-
t ft in.
3.Well Use(check well use): ft I ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural Municipal/Public fit. ft in.
Geothermal(Heating(Cooling Supply) _ Residential Water Supply(single) ft. fit in.
--'Industrial/Commercial OResidential Water Supply(shared) 19:GROUT
irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUII'r
Non-Water Supply Well: 0 ft fit 2 S+
Monitoring pRecovery ft.
injection WReell:
__Aquifer charge Groundwater Remediadon fL ft.
PACK
Aquifer Storage and Recovery 19.SAND/GRAVEL if applicable)Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. I ft
Experimental Technology OSubsidence Control ft ft
Geothermal(Closed Loop) DTraeer 20-DRILLING LOG attach additional sheets if necessary).
DGeothermal(Heating(Cooling Return) ' Other(explain under#21 Remarks) FROM TO DESCRIPTION color,h2rdoess,wil/mek type,
, rein sl2r,ere.
© k. ft t? J
4.Date Well(s)Completed:/ --2.2—Weil ID# ft 1/5— ft C _ L
Sa.Well Location: it 2 t G 4 t Z 1
eo
ft ft.
�J+Facility/Owner Name Facility M#(ifi applicable) ft. ft
.�'- !�� f-`,�!`�►1[" Z.(`�T (`�1.G �T�IL�SG��C,. fit fL
Physical Address,City,and Zip `'i '-,C 'Z?5 l 5- 7 fL ft
a-tG )`lI� 21.REMARKS
County I Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N W
6.ls(are)the wells ermanent or OTemporary Signature of Certified WellContrdc r Date `
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E3Yes or No rvith 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this it a repair,fill aid known well construction information and explain the nature of the cepy ofthiT retard has been provided to the well owner.
repair under#11 remarks section or on the back of this farm.
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
depth
9.Total well st below land surface: ( ) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wefts list afl depths if different(example-3@200-and 2@1001 construction to the following:
10.Static water level below top of casing: 3 (fL) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+/" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 011-) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
/7 /"�/ 1 ` above,also submit one copy of this'form within 30 days of completion of well
12.Well construction method: 4 G /L I
(Le.auger,rotary,cable,direct push,etc.) —� construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) Method of test 51 24c.For Water Supply&Iniectio'n 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: J�/ Amount: L U �. 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