GW1-2023-01883_Well Construction - GW1_20230222

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only: Print Form
1.Well Contractor Information:
Chris King 14.WATER ZONES i I
Well Contractor Name FROM TO ➢ESCRIPTIONJ
2080 A ? fur GTrC;i''1
ft ft
NC Well Contractor Certification Number
IS.OUTER CASING for multi-cased wells OR LINER if a {iMAT
Aqua Drill, Inc. FROM To DIAMETER ; Tffict __A MATERIAL
2 ]
Company Name ft ��i'in.
16.INNER CASING OR TUBING Geothermal closedloo) LJ
2.Well Construction Permit#::tJn 22 f 0 51 FROM I To rA D IETER T11ICKNESS MATERIAL
List all applkbable well construction permits(i.e.WC,Coual;;Stale,Varianc4 etc.) ft.
3.Well Use(check well use): 1K ft I in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TRfCK10ESS MATERIAL
H7Agricultutai DMunicipaliPublic & is
Geothermal(Heating/Cooling Supply) Alkeideatial Water Supply(single)
HIndustrial/Commercial DResidential water supply(shared) 18.GROUT
Inigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. -_ ft. min -
Monitoring Recovery ft f(
Injection Well:
ft. rL
Aquifer Recharge [30roundwaterRemediation
I9.SAND/GRAVEL PACK tf a ticable
Aquifer Storage and Recovery OSalinity Barrier FROM I To I MATERIAL I EMPLACEMENT MET110D
Aquifer Test DStorrwater Drainage ft. &
Experimental Technology [3Subsidence Control ft. ft.
Geothermal(Closed Loop) ElTracer 20.DRILLING LOG attach additional sheets Kneces
Geothermal(Heating(COoling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardnes&sallfro-type,grain size,etc
4.Date Well(s)Completed: '02 3 WeR m ft• ft:
ft ft
Sa Well Location:`9�
ft. ft ,
Facility/Owner Name Facility ID#(ifappllcsble) ft. ft. ' s`- yV 4� y
FEB 9,
���t�5 l�`IZ�E'rCrta�':. � rt. � 'Physical Address,City,and Zip a7D©(7
2LREMARKS t.,,I P i `;'?Jio'�R�1l;Ri!
County Parcel Identification No.OMO h!
d'e 1j.7ti
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field•one lat/loagis sufficient) 22.Certifie tion:
Y W
Q -3-.2
6.Is(are)the vvell(s)ffpermanent or Temporary Signature ofCe ed W Conaac Date
,�� By signing this fame,I hereby certifp that the well(s)aas(were)constructed in accordance
7.Is this a repair to an existing well: Gws or �No ivilh 15A NCAC 02C.O100 or 15A NCAC 02C.0200 Well Construction Standards and that a
ljOris is a repair,fill out larona well cous[nnction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair.under#21 remarks section or on the backofthisform.
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 I 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: < rti� (ft) 24a.For All Wells: Submit thin fort within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2 a@100� construction to the following:
10.Static water level below top of casing: 570 (ft) Division of Water Resources,Information Processing Unit,
lftrater level is above casing,use '+' - 1617 Ma17 Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in-) 24b.For Iniection Wells: In additi In to sending the form to the address in 24a
12 Well constrnetion method: L 1/_ above,also submit one copy of this form within 30 days of completion of well
(Le.auge,rotary,cable,direct push,ete.— r--- construction to the following.
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Nnlderground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m _
�p ) �_Method of test: iG]�_ 24c.For Water Sumly&Injection Wells: In addition to sending the form to
V the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: E� t� completion of well construction to i e county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of WaterResources Revised 2 22-2016