GW1-2023-01934_Well Construction - GW1_20230222

I �
_Print Farm ?
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES I I
Well ContractorName FROM TO DESCRIPTION
2080 A 1,20 It
NC Well Contractor Certification Number 15.OUTER CASING for multi-ased wells ORLINER rf a licable
Aqua Drill, Inc. FROM I To I DIAMETER THICKGNE�SS MATERIAL
Comparty Name
// ft-
16. CASING ORT INGfeeothernial closed-leoul
2.Well Construction Permit#: j� iPr���'` d"11rr� _ FROM TO DIADIErER THICKNESS MATERIAL
List all applicable well construction permits(Le.WC,County,State,Variance,etc.) & 'ft In.
3.Well Use(check well use): ft, It. In.
Water Supply Well: 17.SCREEN \
FROM TO ET DIAMER SLOT STLE THICKNESS' MATERIAL
bicultural OMunicipatTublic fL ft. I.
Geothermal(Ifeating/Cooling Supply) $esidential Water Supply(single) ft. ft iu
Industrial/Commereial OResidential Water Supply(shared) 18.GROUT
I>ri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 10
ft. f ,
Monitoring pRecovery ft. ft.
Nection Well:
ft, ft
Aquifer Recharge 0GroundwaterRemediation
19.SAND/GRAVEL.PACK(If a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
quifer Test OStomrwater Drainage ft ft
Experimental Technology [3Subsidencc Control ft. %
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating(Cooling Retum) '—Other(explain under#21 Remarks) FROM I TO DESCRIPTION(color,hardnw,sniltrock t rain size,etc.
4.Date Wells)Completed:=T Well ID# —0 ft. q() ft u,�_ . 9 O C/i
Sa.Well Location: Cr 0 ft• -5 lj l) e I
Facility/Owner Name Facility M#(ifapplicable) ft• ft t'"' L—5 r 4
1�6 �Cll+c�1NC -1+ I�uxor �,t�ftl�fj�/�� �' F-
Physical Address,City,and Zip I ft. &
21.REMARKS i S-
County Parcel Identification No.(PIN)
:t'C?/aOG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Ce ca n:
l — _
w _ 3
6.Is(are)the wells ermanent or OTemporary SiguZue of Certified We Contractor Date
By signing this form.I hereby certify that the well(s)wns(were)constructed in accordance
7.Is this a repair to an existing well: ,�.'1Yes or TO with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
Iftltis it a repair;fill Out lotbnm well construction information and explain the nature of the copy ojthis record has been provided to the well owner.
repair,under#21 remarks section or on the back of thisform.
23.Site diagram or additional well details:
3.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 I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
�ry SUBMPPI•AL INSTRUCTIONS
9.Total well depth below land surface: of�. O 24s.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi,#'erent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing-, Division of Water Resources;Information Processing Unit,
1j,vater level u above casing tore+� 1617 Matz Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (/P (ia) 24b.For Injection Wells: In addition to sending the form to the address in 24a
11 Well construction method: 4 z z 1 I ' above,also submit one copy of this form within 30 days of completion of well
(' g rotary,cable direct us eEc ' w construction to the following.
Le.auger, , push, )
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,i Raleigh,NC 27699-1636
232.Yield(gpm) Method of test: 24c.For Water Simply&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:-/�T� Amount:`_'_/ (�• completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmental Quality-Divisionof Water Resources Revised 2-22-2016