GW1-2023-01932_Well Construction - GW1_20230222

Vt'ELL CONSZ'RUC�`ION itECOR1D GW i For Internal Use Only I I Print Form
: —
L Well Contractor Information: I
Chris King
14.WATER ZONES P I
WellComractorName FROM TO DESCRIPTION
2080-A fr• ft I I
.I
NC Well Contractor Certification Number ft• ft.
Aqua Drill,Inc. 15.OUTER CASING formulti-casedwells ORLINER ffa 11cable
FROM TO DIAMETER THICKNESS MATERIAL
Company Name Q fL fr. Sf� in. .//�"(j i
2.Well Construction Permit# 1& R CASING OR TUBING(eothermal close''dSSa�
INNER
f FROM TO DIAMETER THICKNESS MATERL�L
List all applicable well constrrtelton permits(ce.ULC,Camq;State,Irtrtance,eta) ft. % is
3.Well Use(check well use): ff ft in
Water Supply Well: 17.SCREEN
Agricultural FROM - TO DIAMETER SLOT SIZE TRICRNESS MATERIAL
Municipal/Public ft �
Geothermal(Heating/Cooling Supply) Residential Water Supply(ogle)
Industrial/Commercial ft. & to
Residential Water Supply(shed)
hri tion 18.GROUT
FROM TO MATERML E\il'LACEMENT hIETHOD&AmOUA'T
PIon-Water Supply We11: fr. I>:
C Monitoring - 4 C
Recovery % �Injection Well:
AquifcrRecharge 1�GroundwaterRemediation ft. fr
Aquifer Storage13SalinityBamer 19•S /GRAVELPACK da h'cable
FROat TO MATE RGIL EMPLACEMENTMETROD
Aquifer Test 0SWoriwater Drainage ft. ft
Experimental Technology Subsidence Control
_Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if access
Geothermal(Heating/Coohrig_Retum�)i Other(ex lain under#21 Remarks) FROM To DESCRn'TION color,hardness solUmck t „Ia size ec�
4.Date Well(s)Completed: .G�S - W p -
G� s17vc�'; jZcG,C
Sa.Well Location: ft
�ckP� Fps�--- 4 I' ' t
t` Facility/Owner Name U` r� (� F c,lity ID#(ifapplicable)' 51'G
�.
. ft
Ph�-.6�Adss, i ,anp ft
I�� 4 2-REMARKSJ�/
County
Parcel IdeadficationNo.(PIN)
Sb-Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient)
22.Certification:
n W
6.Is(are)the well(slop—nent or ©ITemporary Signature ofCertrficd well Con ctor ; Date
yes p By$18ning this form,I hereby aI that lie ivell(s)was(were)constructed in accordance
7.is this a repair to an existing well:
Ifthis is a repair,fill ont/olown well constnction it f0rmation lani�nature o the copy ofd+6'With 15A �cord h Obeen100 or vi NCAC 02C.0200 Well ConshucNon Standards and that a
repair under#21 remarks section ar on[lie back ofthis form. f provided to the rie11 owner.
23.Site diagram or additional well details:8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,Only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled;
SUBMITTAL INSTRUCTIONS
.9.Total well depth below land surface:_ �-'/ � -.
For muhiple wells list all depths ifdifferent(eromple-3(( 00'and 2(a1100) (fk) 24a.For All Wells: Submit this form within 30 days of completion of well
/ construction to the following:
10.Static water level below top of casing: to 0
Fjivater level is above caging,use"+•• (ft) Division of Water.Resources,'Information Processing Unit,
1617 Matz Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (1 ) ,
1 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Ale i Z, 1 above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct pusb,eta) construction to the following:
I
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
�) 1636 Ma11 Service Center;Raleigh,NC 27699-1636
13a.Yield(gpm) ' Method of test:_ Its� _ 24c.For Water SunDI$ &Iujection Wells: In addition to sending the form to
13b.Disinfection type.. Amount �T the address(es) above, also submit onel copy of this form within 30 days of
completion of well construction to the county health department of the county
Foram GW-1 North CarolinaDegattrnent ofEaviromnental where constructed.Quality-Division of Water Resources
Revised 2-22-2016