GW1-2023-02088_Well Construction - GW1_20230307

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WELL CONSTRUCTION RECORD(Gw 1) For Internal Use Only: — - -
1.Well Contractor Information:
Chris King 14.WATER ZONES I
Wetl Contractor Name FROM TO DESCRIPTION
2080 A 1C� ft S l
ft. ft.
NC Well Contractor CertificationNumber
15.OUTERCASING for multi-cased wells OR LINER ifa cable
Aqua Drill, Inc. FROM To DWMETER THICKNESS t[MATERi-1
Company Name ft• ti
2209
� _ 16.INNER CASING OR TUBING eothermal closedLloo
2.Well Construction Permit#: V 0 0 FRORt TO DIAMETER TiUCKNESS KALTERUL
List all applicable well construction permits 0-a WC,Cormq;State Varian-,etc.) ft. M in
3.Well Use(check well use): % ft. in
Water Supply Well: 17.SCREEN
. A CUl1a1'dl FROM -TO DIAMETER SLOTSIZE THICKNESS MATERIAL
MunicipaMblic tt it in.
Geothermal(Heating/Cooling Supply) sidential Water Supply(single)
ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
.. .I ate FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT'
Non-Water Supply Wen: ft. ft: el� Ella}
Monitoring EIRecovery iL fL 1 l
Injection Well:
Aquifer Recharge oGroundwaterRemedianon ft ft.
Aquifer Storage and Recovery Illl Sal' ' Barrier 19.SAND/GRAVEL PACK d applicable)
ty FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. %
Experimental Technology E3Subsidence Control fr. ft
Geothermal(Closed Loop) 0I7racer FDiEO�TGHOG attach additional sheets KneesGeothermal(Heating/Cooling Return) � Other(explain under#21 Remarks) TO DESCRIPTION color,hardness;5awruck a rain sin,etc.t �� 14.Date Well(s)Completed:/ 3t23 WellID# A►etc izcdc Lie
Sa Well Location:
0 •a ©fir z s`S+L ft.
Facility/OwnerN-We Facility lD#(if applicable) R ft
tt a t ': R
Physical Addressi City,and Zip ft. ft. NAAR t i
OCr i b i C I i 111°1"{ 2L REN ARlcs l'
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in d jA `•J"gt agrees/minutes/seconds or decimal degrees:
(ifwell ficld,one latilong is sufficient) 22.Ce tlon:
N W /
6.Is(are)the well(s) P-manent 'or oTemporary SignatureofC.rd—fi eltCo ctor
Date
By signing this farm.I hereby certify that the WHO xns(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or J5No with 15,4 NCAC 02C.0100 or ISA NCAC 02C.0200 Welt Construction Standards and that a
If this is a repab;fill Out known well construction Information and explain lire nature of the copy ofthis record has been provided to the uW1 mvnm
repair wider#21 rwnarks section or on the back of this form.
23.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 if necessary.
drilled:
c SUBMITTAL INSTRUCTIt)NS
9.Total well depth below land surface: J (9 (it) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different&n;;ple-3 200'and 2@l00`j
111, construction to the following:
10.ireter level is above casing.use
water level below top of casing:
If u L1 (ft.) Division of Water Resources,Information Processing Unit,
"+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method- (A above,also submit one copy of this form within 30 days of completion of well
(Le.-get,rotary,cable,direct push,etc) construction to the following.
i
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) SC) Method of test:-�iC�� + 24c.For Water Supply 8r Injection Wells In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: Amoant: t9 completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016