GW1-2023-01933_Well Construction - GW1_20230222

_Print Form
WELL CONSTR11JCTION RECORD(GW-1) For Internal Use Only.
I.Well Contractor Information:
Chris King 14.WATER ZONES
Well ContractorName - FROM TO I DESCRIMON
2080-A fr 5:2 fl- IA
NC Well Contractor CertificationNumber
f• P
15.ODTER CASING for multi sed wells OR LINER d a livable
Aqua Drill, Inc. FROM To DUlMETER - TffilNER MATERIAL
U ft Qj fr. i . 6 /!f
Company Name � n t/g
i� � F16.ROM ER CASING ORTIJB ME thermal dosed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
Lis,all applicable xell construction permits(f e.UIC,Cotmt}:State Parlance,etc.) ft. fG in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN
FRONT TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural �MutticipaVPabGc tt ft is
Geothermal(Heating/Cooling Supply) Mkesi&otial Water Supply(single) ft in.
IndustriaUCommercial OResid'n id Water Supply(sbared) 18.GROUT
Irri tiOR FROM I TO MATERIAL EMPLACEMENT METHOD&Ah10U1,T
Non-Water Supply Well: it ft. e
Monitoring pRecovery g &
Injection Well:
ft
Aquifer Recharge ElGroundwaterRemediation�Salinit
Aquifer Storage and Recovery19.SAND/GRAVEL PACK if a lleabie
yBatrier FROM To I nwTERinL' EMPLACEMENT METHOD
Aquifer Test 09tormwater Drainage ft it
Experimental Technology oSubsidenc.Control ft it
Geothermal(Closed Loop) OTrd= 20.DRILLING LOG attach additional sheets iinee
Geothermal(HeatinglCooling Return) 130ther(explain under#21 Remarks) FROM I To DESCRIMON color,hardness,sail/mckr rota size,etc.
fw ( ) It C% t
4.Date Well(s)Completed __-^L Wel1ID1€ ft or, It J 6/J ,
Sa.Well Location: 6 ft. 1 1 ft
ft. ft 9 Q ¢' 'k ,ter
c
Facility/OwnerNamg Facility ID#(ifapplicable) ft ft
21
1336 - `V Physical Address,City, dZip h. It inifarr"i-'. t3l P rcc- 3 DRi z
ie
21.RER7ARKS
Count' Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certific lion:
N W
6.Ware)the wel](010hrmanent or. Temporary Stgoatttre ofCcrtified VVA Contiacibr Date
By signing this farm,I hereby certify that the acU(s)was(were)constructed in accordance
7.Is this it repair to an existing well: FlYes or(136 with 15A NCAC 02C.0100 or Im NCAC 02C.02ao Well Construction Standards and that a
Ifthis is a repair,fill out!Drown well construction h formalion and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under#21 remarks section or an 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 ofwells construction details. You may also attach additional pages ifnece,,wy.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: _ 00 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells hit all depths ifd fferent(example-3��000''a�ad 2@100� construction to the following
1Q Static water level below top of casing: J (ft) Division of Water Resources,'Information Processing Unit,
]Jrvater level is above casing rose"+' 1617 Marl Service Center,Raleigh,NC 27699-1617
11.13orehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: ICZ above,also submit one copy of this forrn 'thin 30 days of completion of well
(Le.auger,rotaty,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 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Suonly&Injection 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:,/to /��� completion of well construction to the county health department of the county
where constructed.
Fonn GW-1 North Carolina Department of Euvinonmental Quality-Division of Water Resources Revised 2-22-2016