GW1-2023-02093_Well Construction - GW1_20230307

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i
, 1.Well Contractor Information:
Chris King 14.WATER ZONES I
FROM TO DESCRIPTION
Well Contractor Name
2080-A 'SI0 ft. 1 C�1 ft. 1 O 6-if?11..
NC Well Contractor Certification Number ,V15 15.O O it.UTER CASING SItNG(foo f (la /),),r,l
r multi-cas(ed7 wells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name © ft.
97 `:-/ 50/z. i RV EC
ry 16.INNER CASING OR TUBING(geothermal closed400p)
2.Well Construction Permit IF: I�L.) D''`)! ` Q )g FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction perms (i.e,fC,County State,Variance,etc.) it it in.
3.Well Use(check well use): ft, ft. in
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL .
Agricultural 0MunicipaUPnblic it ft in.
Geothermal(Heating/Cooling Supply) ,, Residential Water Supply(single) fw ft. in.
Industrial/Commercial OResidential Water Supply(shared) -
10,GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a ft 0 ft' 4 4lir l e C t 1 D 5
Monitoring IRRecovery ft. ft. I
Injection Well:
ft. ft.
Aquifer Recharge jjaroundwaterRemediation
19.SAND/GRAVEL PACK Cif applicable)
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
,Aquifer Test DStormwater Drainage it it
Experimental Technology OSubsidence Control it ft. '
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soli/rack type,grain size.etc.)
Geothermal(Heating/Coolin3 Return) Other(explain under#21 Remarks) a ft. `,a tZ t7 { t{�
4.Date Well(s)Completed.. «3-23 Well ID# 3,r ft, f-�" ft' ���1k-r �,t„ ,
5a.Well Location: (10 ft. lts—ft- a/0e 6-row--4 - '`-:,?
ft. ft. n .U,...
Facility/Owner Name Facility 1D0(if applicable) ft. ft MAR a 7 2023
%72 L r us
icr Foq rer iki K-el trik Se jv,.0 ft. ft. . i ri.t
Physical Address,City,andZip ft• ft. ifsiGir<=;- -"1 ,.',,>�+ j
goer- l rhs n1 21.RElt4Al1KS
County 1 Parcel Identification No.(PIN)
5b.Latitude and longitude in:degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifi don:
N W ' -Z� 13
6.Is(are)the well(s)gRermanent or Temporary Signature of Certified Well Contrdctar ate
By signing this form,I hereby cert('that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ()Yes or Ao with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair;fill out known well construction it formation and explain the nature of the copy of this record has been provided to the well owner
repair under€#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/1DPT 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: S- (ft-) 242.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(examp e-3Q200'and 2©100) construction to the following:
10.Static water level below top of casing: q 0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. C (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: A t IZ t 'lC 1 I,i construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: �T i 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 100 Method of test S uy 24c.For Water Supply&Injection Wells: In addition to sending the form to
J the address(es) above, also submit one copy of this form within 30 days of
/j
I3b.Disinfection type: 1 7 Amount:9 0 Z.. completion of well construction to!the county health department of the county
where constructed
Form GW-1 North Catalina Department of Environmental Quality-Division of Water Resources Rovised 2-22-2016