GW1-2023-01445_Well Construction - GW1_20230208

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WELL CONSTRUCTION RECORD(GW-2) For Intemal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM I To DESCRIPTION
2080-A Sty_fry`` O
NC Well Contractor Certification Number ) fr III e fr ,
15.OUTER CASING for mrlti-cased well OR LINER tf a livable
Aqua Drill, Inc. FROM TO DIAMETER T�ctaaE4s MATERIAL
Company Name v rLle"-3ft. G J/5- in. &
r ,2.Well Constriction Permit#: 9 ( � 16.INNER CASING OR TUBING thermal closed-loop)
y FROM TO DIAMETER J THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,Count),State,Variance,e1c.) fL ft. is
3.Well Use(check well use): ft. ft. im
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TRICKNESS MATERIAL
AgriculWmi MunicipaVPubfic fL ft, in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single)
ft, fL in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
_hTigation. FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-water Supply well: © ft- -2 o ft U 7 e S
Monitoring ORecovery ft. ft.
Injection Well:
ft. fL
Aquifer Recharge Groundwater Remediation 19.SANDIGRAVEL PACK Ofapplicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
quifer Test J3Stom water Drainage ft. R
Experimental Technology Subsidence Control ft. fL
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG attach additional sheets if n
Geothermal(Heating/Cooling;Return) MOther(explain under#21 Remarks) FROM TO DFSCRIP r10N(color hard sofifracktyM Strain size,etc.
4.Date Well(s)Completed: L)` Well}D# fL �' R )Lb C
5a.Well Location: ft ft G Z C-
ft. R
Faccilliityy//Owner Name Facility ID#(if applicable) ft fL ?� ap-i.
Physical Address,City,and Zip M R
10MANiC 'C� 21.REMARKS RF-g;,Q&rQ t
County Parcel Identification No.(PIN) :dl
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certific tioa:
it W 9 -.9 3
6.Is(are)the well(s)6--anent or OTemporary Signature of Certified Well Contractor I Date
By signing this form,I hereby certify that the wells)cons(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No with 15A NCAC 02C.0/00 or 15A NCAC 02C.0200 Well 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 coal/owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
S.For GeoprobelDPT 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: J C� (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: c2 00 Division of Water Resources,Information Processing Unit,
Ifwttter level is above casing,use-+" 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: cea (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: 1 17_ a-, I 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
23a.Yield(gpm) fJ Method of test aC V1 J24c.For Water Supply&Infection 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: r� Amount: C Z completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmcntat Quality-Division of Water Resources Revised 2-22-2016