GW1-2023-01935_Well Construction - GW1_20230222

WELL CONSTRUCTION RECORD(Gw 1) Print Forrn
For Internal Use Only_ -- -- _
1.Well Contractor Information:
Chris King
Well Contractor Name 14.RATER ZONESFROM To DESCRIPTION
2080-A / it.
NC Well Contractor Certification Number
Aqua Drill, Inc. 15.OUTER CASING for muld-cased wells OR LINER ifa [icable
FROM To DIAMETER TmcnmSs TERTAL
Company Name ` 16.
© NEtt. / • it. / `J�� in. 1` `
2.Well construction Permit#:�O }t;�( 16.INRCcASSINGORTUBING eothermalclosed-1ao !�
FROM TO DIAMETER TriICKNFSS ,yLe,TERIgL
List all applicable well consaucllon permits(i.e.UlC,Comriy State,vananc4 etc.) @; R in.
3.Well Use(check well use): & ft is
Water Supply WeII: 17.SCREEN
cultural FROM TO DIAMETER SLOT SIZE THICKNESS &IATERIAL
-- Atid
f<•Geothermal(Heating(Cooling Supply) ential Water ft. in.'
(single)
Industrial/Commercial Residential Water Supply(shared) %
hrioation M GROUT
Non-Water Supply Well: FROni To MATSRIAL EMPLACEMNT METHOD&AMOUh"r
M Q tt; ft.
Monitoring
>J
Recovery � J S
Injection Well: ft R•
Aquifer Recharge E)GmundwaterRemediation it. ft:
Aquifer Storage and Recovery DSalinity Bauder 19.SAND/G PAS s a 11 ble
Aquifer Test FROM To nIATERIAI. MPLACEMENT METHOD
_ �tStoffiwater Drainage ft. ! it, E
Experimental Technology oSubsidence Control ft. X
Geothermal(Closed Loop) 07racer
20.DRILLING LOG attach adttitional sheets if necessn Geothart lal(Heatmg/Coolinc,Return) M'_ r"(mplain under#21 Remarks) FROni TO DES ION(color,hardness,soWrock
f e, rain sire,eta
4.Date Wel➢(s)Completed• j�I '25 Well ID# V� ft.
Sa Well Location: !� � 5r,ryzi lZa ca
Facility/Owner Name Facility ID#(ifapphcable) ft.
P c�t�rl�k,r, c l�elzrr�a�f 1a►15d�rv� ft.
91 ft.
hysicalAddress,City,IdZip �.
�— ft. ft.
i.. 21-REMARKS I" 9, 2023
County Parcel Identification No.(PIN) O
Lg LRiS
5b.Latitude and longitude in degrees/minutes/seconds or decimal des: J r5(ifwell field,one lat/longis sufficient) egre
22.Certific don:
W.
6.Is(are)the well(s) permanent or Temporary
66''�_ Signature ofCemfied Well Contractor Date
7.Is this a repair to as existing well: Yes or a Bp signing this form.I hereby cerwfi,that the wells)ulls(were)constructed in accordance
Ythis is a repair fill out known well construction information tCCannd�rra___xplain the nature o the cePY fdr with 15A Nr a ord has beenpro
r 1SANCAC 026.6200 Well Construction Standards and that a
repair under#21 remarks section or on the back of this fonn. f provided to the weft owner-
he
Site diagram or additional well details:
S.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:
SUB MIT3AL INSTRUCTIONS
9.Total well depth below land surface:
For multiple ivells list aft depths ifdiffererrt(emmple-3Qa 200'and 2@1005 (fL) 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: `'
Iftvater level is above casing,use+^ (ft-) Division of Water Resources,Information Processing Unit,
1617 Marl Service Center;Raleigh,NC 27699-1617
11.Borehole diameter: CID
j' 24b.Eor Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method:—�� ) EZ ` lZi above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc) construction to the following.'
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
13a.Yield(gpm)_ 1636 Mail Service Center,Raleigh,NC 276994636—IQ-- 5 f_
Method of test: 1 I'1 24c.For Water SuMIv&Infection Wells: In addition to sending the form to
13b.Disinfection type:_ Amount: the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
FormGW-I North Carolina Department of EnvirOmneutal Quality-Division ofWaterResources i
Revised 2-22.2016