GW1-2023-00998_Well Construction - GW1_20230125

___ Pr_intF'r_m_ i
WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080 A Jg6% �� & a
IL ft-
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LL�IER d a licable
Aqua Drill, Inc. FROM To DIAMETER THI MATERIAL
Company Name
f 16.INNER CASING OR TOBING(eothermal closed4000l
2.Well Construction Permit#r Cl 1 tit yu Z2 FROM To nlAntETER THUCKNESs I MATERIAL
List all applicable aril construction permits(i e.UIC,Cahod};State,Varlance,eta) ft. ft-
In.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSME THICKNESS MATERIAL
Agricultural 0Municipal/Public fL ft. in.
Geothermal(Fleating/Cooling Supply) ffRgsidential Water Supply(single)
.. io.
: rndustrial/Commercial Residential Water Supply(shared) fL IL
is.GROUT
... Hgation FROM I TO MATERIAL EMPLACEMENTMEMOD&AMOUNT
Non-Water Supply Well: ft. U ft. )vl 6 k t
Monitoring DRecovery fL ft.
Injection Well: ft. IL
er Rech
arge barge GmundwaterRemediation 19.SANDIGRAYELPACK(if a linable
DAquifer Storage and Recovery Salinity Barrier FROM TO AIATERML T EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft• fL
Experimental Technology OSubsidence Control fL ft.
Geothermal:(ClOsedLoop) QTracc, 20.DRILLING LOG.attach additional sheets'ifn
Geothermal(FIeatin Cooling Return) • Other( lain under#21 Remarks) FROM To DESCREMON"eoto4 hardness,sou/mck rats 5I•e[e
ft6 f- 1.
4.Date Well(s)Completed: 7 ) _2-5 Well ID# ft. rt 5M)81 �O
Sa.Well Location; (� " 3 be
4.t 1A 9�.5'�A,t- I ft. ft
�Faciility/OwaerName Facility M#(ifapplieable.) ft. fL
) j
Physical Address,City,and Zip ft. ft.
. h4in A"� L L cA— 1,� 21.RENAM 5 823
County Panel Identification No.(PIN)
•try 'v. �v. rwa
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: y
(ifwell field,one tatilong is sufficient) 22.Certification:
If W
6.Is(are)thewell(s) Permanent or 0Temporary Sigmdm—ofCeitified— Weld r Date
By signing this form,I hereby certify that the wells)um(were)constructed in accordance
7.Is this a repair to an eidsting well: DYes or ANo with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Slandardrand that a
YIN.is a repair,fill out known well construction information and explain ilia nature ofthe copy ofthis record 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:
S.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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled:
SUBNIITTALINSTRUCTIONS
9.Total well depth below land surface: (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list ail depths ifdifferent(example-3 o200'and 2@100) construction to the following.
10.Static water level below top of casing: J� (ft) Division of Water Resources,Information Processing Unit,
Ifwater level&above casing,use•'+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: /7 j ]2 )-z � ) above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct pusb,etc) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Suonly&Injection Wells: In addition to sending the form to
)4
7 the address(es)above, also submit one copy of this font within 30 days of
136.Disinfection type: f Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEm ironmental Quality-Division of Water Resources Revised 2-22-2016