_Well Construction - GW1_20230315 (27)

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WELL CONSTRUCTION IR3ECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A Oft' 2 l
NC Well Contractor Certification Number ft. I ft
15.OUTER CASING for multi-cased wells OR LINER if a u ble
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft. ft. &1/-f b,. 5 IZ 7 l i ,/O C
9 7 ./l1 ) p� 16.INNER CASING ORTUBING(eothetm21 closed-loon)
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2.Well Construction Permit#:� y .� Z —tJ FROM TO DIAMETER MCK NESS MATERIAL,
Listallapplicable nellcoustructionpermits(i,e.UIC,Cmmq;Srate,Variance,etc) ft ft Ln.
3.Well Use(check well use): Et. ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural nMunicipat?ublic ft ft in.
-Geothermal(Heating/Cooling Supply) residential Water Supply(single)
ft ft in.
IndustriaUConmmercial DResidentiai Water Supply(shared)
MIrri18.GROOT
FROM TO 6fATERIAL EMPLACFDiENT METHOD&AMOUNT
Nonn-Wate ater Supply Well: A 1 I�� —
Monitoring Recovery ft ft.
1
Injection Well:
A uifer Recharge it. ft
q g �GroundwaterRemr:dia6on
Aquifer Storage and Recovery Salim Barrier 19•SAND/GRAVEL PACK if a ILeable
ty FROM I TO MATERIAL. EMPLACEMENTMETHOD
_ Aquifer Test oStommvater Drainage ft ft
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) i]Tracer 20.DRILLING LOG attach additional sheets If neces
Geothermal(13eating/Coolingneturn) Other(explain under#21Remarks) FROM TO DESCRIPTION colorhnrdne%wivmckt � ralasizeerel
4.bate Well(s)Completed:2 -23 Welt W4 $ ft. 9 ft.
5a.Well Location: 1UC C,� - LI 1 PCFacility/Owner Name Facility lD#(if applicable) R• ft
l tv�;ic cep 17d i'A1;'/1) s c ft. ft�
PhI it Address,Ci ,and Zip P)73 10
tT. ft
�7crkl Nch�Ivt Df Zi.REMARKS
County I
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latltongis sufficient) 22.Cer ation:
1v W = a-
6.Is(are)themell(s) rmanent or DTemporary Signature of Cw fied WeR Con ctor Date
By signing this form,I hereby'certify that the irell(s)urns(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or No with 15A NCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jill out/atowm well constnrcHort information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under t#21 remarks section or our the back of thisform.
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 ofwells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 9 5 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdtfferent(example-3@200'and 2@100)
� construction to the following:
10.Static water level below tap of casing:_
Ifwater level (ft) Division of Water Resources,Information Processing Unit,
a above casing use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: 1 ) f� 4 IZl I.I above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct push,eta) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
(-
1636 Marl Service Center,Raleigh,NC 276994636
13a.Yield(gpm) Method of test:_�i(iii h �`1 24c.For Water Sunniv&Injection 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: 14TA _ AmoI 0 2- completion of well construction to the county health department of the county
where constructed.
Farm GW-1 North Carolina Department of Environmental Quality-Division of WaterResourres
Revised 2-22-2016
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