GW1-2023-00996_Well Construction - GW1_20230125

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WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only
1.WeIl Contractor Information:
Chris King 14.WATER-ZONES
Well Contractor Name FRONT TO DESCRIPTION
2080-A 90 It Iqs'—'L s�-t7
ft. tt
NC Well Contractor Certification Number
15.OUTER CASING for multi-eased wells OR LINER tf a licahle
Aqua Drill, Inc. FRONT To DIAMETER THICKNESS MATERIAL
Company Name
0 ft. L j ft.
] �y 16.INNERCASINGORTUBING eothermalclosed-loo`,
2.Well Construction Permit#:!�1 l 9 y e'-";r-'-j ret FROM I To I DIAMETER I THICK MESS MATERIAL
List all applicable well construction permits(i.e.UIC Couny;State,Variance,etc.) ft ft id
3.Well Use(check well use): % ft in.
Water Supply Well: 17.SCREEN...
Agricultural FRONT TO DIAMETER SLOTSI7.E THICKNESS MATERT.4L
Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) ,residential Water Supply(single) ft ft is
Industrial/Commeraial DResidential Water Supply(shared) 18.GROUT
hri at10n FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water-Supply Well:
` ft ft ��0
-- 1
Monitoring Recovery ft, ft,
Injection Well:
-.Aquifer Recharge Groundwater Remediation ft ft.
Aquifer Storage and Recovery CK[)Salinity19.SAND/GRAVEL PA if Ueable
Salinity Barrier FROM To I MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwaterDrainage ft. -M
Experimental Technology [3Subsidence Control ft. ft
Geothermal(Closed Loop) [3Tracer =20,DRILLING LOG attach'additional sheets if nee
Geothermal(Heating/Cooling Return) nOther(e lain under#21 Remarks) FROMI To DESCRiPTIOPi'cola,hardness,solUrock Sim etc
" _� ize� Ci
4.Date Well(s)Completed: 5 Well ID# ft p S it cJ Y;o Cr-
Sa.Well Location:/n► ( -t,, ,�,� 5 It
9 Cj ft �1 C &l't-L fw-1c
Facility/Owner Name Facility ID0(if applicable) 1 It. 1 ��It )` c
?d; k 11 :5 Kt'MCS iVl L) aeay ft. ft
Physi)cal Address,City,and Zip rV ZC, ft ft I I P N 11 ir+-C(f L--o-t-D&Q 21.REMARK6 �y.�
County Parcel Identification No.(FIN)
JAN ' 0" 3 h Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ' ''
(ifweU field,one lat/long is sufficient) 22.CR:�
i1lEt3i"Ff1a:ADT1}'ri�sJoob^-3 Una`t W r' DWOMOG —/
6.Is(are)the well(s) P`ermanent or OTemporary Signature of Certified Well Contractdr 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: [3Yes or nNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction inform and explain the nature of die copy of this record has been provided to the well owner.
repair under#21 remarkr 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:
99 �j ` SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 f J (fL) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths irdif ferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: W (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: a'. ZI t 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:
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 l ��- 24.For Water Supply&Injection Wells: In addition to sending the form to
n the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: _ Amount: O completion of well construction to the county health department of the county
where constructed.
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016
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