GW1-2023-01886_Well Construction - GW1_20230222

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MILL CONSTRUCTION RIPCORD(GW.1) For Internal Use Only:
L Well Contractor Information:
Chris King 14.WATERZONES
Well ComractorName FROM TO DESCRIPTION
2080=A U fr. ft /p----------------
� try
fr. fr. I
NC Well Contractor Certification Number
Aqua Drill, Inc. 15.OUTERCASING formulti-casedwells)ORLINER ffa licabie
FRO51 JTO �K "IAMETER TfUCKNESs MATERIAL
Company Name X ' m [�! C
1
16.INNER CASING OR TUBING eothermal closed Ion
2.Well Construction Permit#: © FROM TO DIAMETER THCKNESS MATERIAL
List all applicable well constructlou permits(i.e. C Cmmt}:Stag Parlance,etc) fr. ft. in.
3.Well:Use(check well use): M ft in.
Water Supply Well: 17.SCREEN
Agricultural []Municipalftblic FROM TO DIAMETER, SLOTSM THICKNESS MATERIAL
ft fr. in.'.
Geothermal(Heating/Cooling Supply) &mdential Water Supply(single)
ft ft
Industrial/Commercial Residential Water Supply(shared) -
liti ation 18.GROUT
FR01f TO MATERIAL EMPLACEMENT METfIOD&AMOUNT
Non-Water Supply Well: Q j r
Monitoring Rec % e h
Injection Well: overt'
Aquifer Recharge DGroundwaterRemediation it. ft:
Aquifer Storage and Recovery 'Sa Barrier 19 SAND/GRAVEL PACK if a licable
FROM TO i MATERIAL EMPLACEMEhTMETHOD
quifer Test OStormwater Drainage fL tt
Experimental Technology oSubsidence Control fr. ft. '
Geothermal(Closed Loop) E37racer 20.DRILLING LOG attach additional sheets If necess
arvI
GeotheliYyal(IieatinglCooliug Return) Outer(ex lain under#21 Remarks) FROM TO DESCRIPTION(color,hardness savmcic a rota Size ecc, -
a ft. ft. `
4.Date Well(s)Completed. J Well 1D# fr. t/5' ft S A) .! ,2 4i C k
Sa Well Location: ^ft ,-ft, Dluc, R qA) A t
ff. ft.
�Fa/c'inlity/ownerName 7 Facility ID#(ifapplicable) fit, fL77
tf:
PhysicelAddress,City,and Zip a72,39 ft. ft. FEB 2 2" Z023
I C�6�J 21.REMARISS
Count
y. Parcel Identification No.(PIN) i fit vr7d=49i 1 P i:•-,w..ca;v.j U n iI
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
I SWCOT,
(if well field,one LaUlong is sufficient) 22.Certification: „
-W Ile-
6.Is(are)the well(s) Permanent or f3Temporary Signature oft_erhfietfWell C8ntmctor "Dal-
Bp signing this form.I hereby catifp that'the xrll(s)xvs(were)consnvcred in accordance
7.IS this a repair to an existing well; l�Yes or .No iv'th 15ANCAC 02C.0100 or 154 NCAt;�01C.0200 Well Canstructlon Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under#21 rernarkr section or on the back ofthis 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 ofwells construction details. Yon may also attach additional pages ifnecessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For muhiple wells list all depths fd jjereat(example-3@200'and 2@100� (ft) 24s.For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static wafer level below g.use op of casing: - Q (ft) Division of Water Resources,Information Processing Unit,
Ifwater level's,above casing,nsp'+^ � 1617 Mail Service Ceutei•,Raleigh,NC 27699-1617
11.Borehole diameter. f
,�I 011) 24b.For Injection Wells: In addition'to sending the form to the address in 24a
12.Well construction method: //>8� ^�1 above,also submit one copy of this within 30 days of completion of well
(Le.auger,rotary,cable,direct pushy etc) 1 construction to the following
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Centex,Raleigh,NC 27699-1636
13a.Yield(gpm) J O Method of test: '' - 24c.For Water S1w I &Iniec ii i 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:ajr� completion of well construction to the county health department of the county
where constructed-
North !I
Form GW-1 Carolina Department of Environmental Quality-Division of Water Resources Revised2-222016