GW1-2023-01481_Well Construction - GW1_20230209

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FR051 TO DESCRIPTION
2080-A �) ft• G
ft. 3
NC Well Contractor Certification Number ^(r ft. ,
15.OUTER CASING far multi cased wells)OR LINER d applicable)
Aqua Drill, inc. PROpf TO DL4METER I THICKNESS NIATERLkL
ft. ft. �.5 rt-
Compatry Name l /g -/;y
�j /� 16.INNER CASING OR TUBING( eathermal dosed-loop)
2.Well Construction Permit#:(tO 1 2 —0,40 7 PRont To DIAMETER THICKNESS MATERLIL
List all applicable well construction permits(i.e.UIC,CormO••.State,Variance,etc.) ft• ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: t7.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural oMunicipaUNblic ft. tt. In.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft it is
IndustriaUCommercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO 6L4TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring ft.
Recovt hSt Y�
Injection Well: _
ft. ft.
Aquifer Recharge DGroundwater Remediation
Aquifer Storage and Recovery 19.SAND/GRAVEL PACK ifs licaolel
A
q g ry QISaImity Barrier FROM TQI MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft• ft.
Experimental Technology DSubsideuce Control fr, fL
Geothermal(Closed Loop) OTracer 20,DRILLING LOG fattath additional sheets if necessa
Geothermal(Heating/Cooling Rearm) E30ther(e lain under#21 Remarks) FROM To DESCRIPTION(rnlor,5ardvess soiVrock type ga n s ze etc.
C-. ft. ft _ t' l ,1 V
4.Date Well(s)Completed: - Well ID# ft' ft' S hyLl ��j
5a.Well Location: G ft. ?�1 'ir. w�
Cctr Alt��� G -ccv� _ iz rt; -
it. Jft.
Facility/Owner Name Facility ID#(ifapplicable) ft. it
SZ 11 5?
Physical Address,City,and Zip 7 f, ft.
P� ft —
/ 21.REMARKS
County I Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certitiea n-
1
W ture of W Contra Date �
6.Is(are)the well(s) tPermanent or Temporary t� 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: OYes or [3No with 15A NCAC 02C.0100 or 15A NCAC 02C-0200 Well Construction Standards and that a
Ifthlr is a repair fill out known well constnrction information and explain the nature of the copy of this record has been provided to the well ownm•.
repair under#21 remarks 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:
J C SUBMITTAL INSTRUCTIONS
/
9.Total well depth below land surface: S (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if d perent(example-3@200'and 1@100�
construction to the following:
10.Static water level below top of casing: CC?lrj (ft.) Division of Water Resources,Information ProcessingUnit,
If water level is above casing,r re//"+" 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
1
.Well construction above,also submit one copy of this form within 30 days of completion of well
(L e.auger,rotary,cable,direct push,etc.)ns method: I Z 1�iZ i i construction to the following:
(i.
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 61Method of test: <1 24c.For Water Supply&Iniection 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: _ Amount:J.2 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016