GW1-2023-00729_Well Construction - GW1_20230113

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Contractor Information:
Chris King 14.WATER ZONES
FROM TO DESCRIPTION d
Well Contractor Name ;�
2080-A -- 4 A r !fR .2 ft
''i. @ri i 41 ft. ft
NC Well Contractor Certification Number U
15.OUTER CASING for multi-cased:wells OR LINER d a livable
Aqua Drill, Inc. JAIN 2023 FROM I To I DLU ETER I THICKNESS MATERIAL
ft. % ft / 5 Z 1 l V c 1.
Company Name , ,Aiyr If: '.�
16JNNERGASING OR TUBING(geothermal do3ed-too
/2.Well Construction Permit FROM TO DIAMETER THICKNESS MATERIAL
#:s� � ^"-.t-;uV•%ic
List all applicable well conshwetion permits(;.e.UiC,Coup!),.State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN
pP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERFAL
Agricultural [)Municipal/Public ft. ft �•
-'Geothermal(Heating(Cooling Supply) Residential Water Supply(single) fr. ft in.
r Industrial/Commercial OResideritial Water Supply(shared) 18.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft' R' I C /
Monitoring DRecovery It M
Injection Well: ft. ft
Aquifer Recharge OGroundwater Remediation '
19.SAND/GRAVEL PACK applicable
Aquifer Storage and Recovery [)Salinity Banter FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft. ft.
JExperimental Technology OSubsidence Control R ft
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heatin Coolin i Return) Other(explain under#21 Remarks) oM TO DESCRIPTION color,hard soiVmek r+ln st>r erg
r c G' �''
id
4.Date Well(s)Completed: `2.. Well ID# G R' ?3 ft- 3/4 ! RZO K
5a.Well Location: ft J�©J R 1`7 14 j
�� dui C1�T(i wtr ft ft
Facilit' OCvner Name Facility ID#(if applicable) R ft
y/
22 )CI I n Loru 12 .9e fdnrt i I� �� ft ft
Ph�ysiccaall Address,City,and Zip [t tt
lz6r/` 4� 'lr'.,/\ 21.REMARKS
County 1 Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W
6.Is(are)the well(s)�r ermanent or 07remporary Signature of Certified Well Conrracta Date
By signing this form,I hereby verify that the wcU(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EJYes or IgNo wtth 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Wet!Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 021 remarks section or on the back of dilsform. 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: Q. (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii fereni(example-3@200'and 2Qa 100) construction to the following:
10.Static water level below top of casing: 60 (ft.) 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: (in.) 24b.For Infection Wells: In addition to sending the farm to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: .4oZ J 12 I I construction to the following.
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 5 �4 24c.For Water Supply&Iniection 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: JIL14 Amount Z- 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