GW1-2023-01446_Well Construction - GW1_20230208

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only. Print Form
1.Well Contractor Information:
Chris King 14.WATER ZONESe
Well Contractor Name FROM TO DEKRIPTION
2080-A 20 ft ft- l 7
NCWeIIContraclorCeltificationNumber It. ft,
Aqua Drill, Inc. 15.OUTER CASING for multieased wells)OR LINER if a livable
FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft. tt Sf ia.
. ('t \l Ia.INNER CASING ORTIIBING eotherm&Itimed-1 2.Well Construction Permit#: ao
~' FROM TO DIAMETER THICKNESs MATERIAL
List all applicable x�eU cOtsduclion permits(t.e. VIC,County,State,frariancc etc) R. ft. la.
3.Well Use(check well use): ft. ft in
Water Supply WeD: 17.SCREEN
Agricultural FROM TO DIAMETER SLOT SIZE TRICKNM MATERIAL
[DMunicipal/Pubfic f ft in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single)
Indushial/CoMmercial ft• ft ls.
�Residentiat Water Supply(shared)
hri lion 1s.GROUT-
Non-water
VA-MOUNT
FROM TO aATERIAL EMPLACEMENT METHOD
Supply Well: Q ft. 6 ft. . )C -
Monitoring '• "i (rt
Recovery ft. R
Injection Well:
Aquifer Recharge C)GmundwaterRemediation it. ft.
3- Aquifer Storage and Recovery [)amity Brie. 19.SAND/GRAVEL PACK if a llcaWe
FROM TO MATERIAL EMPLACEMENT METH Aquifer Test �Stomrwater Drainage ft. ft OD
Experimental Technology Subsidence Control ft 1L
RGeothernal(Closed Loop) 13Tracet 20.DRILLING LOG attach additional ahMs it
Geothermal(lleatin Coo' Retum Other(explain under#21 Remarks FROM TO DESCRIPTION color huaeea soWmek rum du ere
d ft. 6 ft. Z d
4.Date Well(s)Completed: _ 3 Well ID# ft. R :�
5a.Well Location: ft• ^ C t c
Facility/OwrerName Facility bk) f ft
,�736 =tL 7 5 - r1=lz�cs jz� ft. &
Physicat Address,City,and Zip11 ft• r_r
ttjam�,tilc� 21.RENFLJ 8 r a
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one lat/long is sufficient)
22.Certifica'on:
rr w
6.Is(are)the ora
well(s) ermaneat or Tempry
��"�� Si ure ofCectified Well Contractor
7,is this a repair to an existing well: By signing this form,I herebyYes or �No with 15A NCAC 02C.0100 or 15 NCAC 02C.02 that the 100JWell Construction StandardsO
d�1 a
Ifthis is a repair,fill out knowm wail construction Information and explain the nature of the copy of ibis record has been provided to the tvell owner.
repair under#21 remarkr section or on the back of this fora.
23.Site diagram or additiond 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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may aLso attach additional pages if necessary.
drilled: P g ecessary.
2 5- 1�uTTAL
9.Total well depth below land surface: SUB LNSTRUCTIONft)For multiple wells list all depths ifdifferent(example-3Q200•and 2@1003 24a. For All We k: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: _ (�)
Ifwater level is above casing,use Division of Water Resources,Information Processing Unit,
1617 Marl Service Center,Raleigh,NC 27699-1617
il.Borehole diameter. (�)
24b.Por Iaiection Weal: in addition to sending the form to the address in 24a
12.Well contraction method: / 1� 1 1 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.
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276"-1636
13a.Yield(gpm) Method of test 24c For Water SnDDty&Iaiectiou Wells: In addition to sending the form to
13b.Disinfection type:
�� O the address(es) above, also submit one copy of this form within 30 days of
Amount: Z- completion of well construction to the county health
department of the county
where constructed.
Form GW-1 North Carolina De
partment of Environmental Quality-Division of Water Resources Revised 2-22-2016