GW1-2023-02141_Well Construction - GW1_20230303

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WELL CONSTRUCTION RECORD(GW4) For Internal Use Only: - 1
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A / 3.5 /57 ft IS 6,)Pr r
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(iap livable)
Aqua Drill, Inc. FROM TO e "1 DIAMETER� THICKNESS ) MATERIAL
Company Name 0 ft. ^7 ft. f%S e in. ov/ ,V 61.4/"
�!- 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit a:✓ ,3 07., 4.}C41L' v2,Z FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(l.e.11C Counq;State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
Agricultural L FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Municipal/Public ft ft. in,
Geothermal(Heating/Cooling Supply)t.,, esidential Water Supply(single) ft ft in.
Industrial/Commercial DResidential Water Supply(shared)
- I8.GROUT
Irrigation -FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. O ft. /k
Monitoring �Recov � '
Injection Well: c-Y ft, fr.
ft. ftAquifer Recharge °G roundwaterRemediation Aquifer Storage and Recove 19.SAND/GRAVEL PACK(if applicable)
ry °Salinity Barrier • FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStonmvaterDrainage it. it
Experimental Technology °Subsidence Control it, ft
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) FROM TO DESCRIPTION(valor,hardness soiVrocktvpe grain size etc.)
7 0 ft. 3 it RCS 0 fig 1
4.Date Well(s)Complete I '-2J Well ID# 3 ft. cis- ft. s>,.d go c 1�
_5a.WellLocation: C� 75- ft. i,g'c tt. /Toe. /rzAN,-)-e
Ca:-•`�r?- .. Lcii l C ft. 1 ft. (�
Facility/Owner Name Facility 11)0(if applicable) ft. ft. N-,'
tL ,. `r A a; .,
nay ., Aar ;EM
thO e. d , fa ft MAR
1..:.d,,�`
Physical Address,City,and Zip r ft. ft. MA j j , O
�y /{ ��3° � :� 2023
/Co¢n 4 1) Ce 21.REMARKS
'c,.,,,•c:.r t. r�n:�=, :g�Q lir'i
County Parcel Identification No.(PIN) 0,,- ,.,,,. 7
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W ' i
---el r 6.Is(are)the well(s) ermanent or Temporary Signature of Certified well Con etas Date
By signing this form,I hereby certify that the wells)uus(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or °No - with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out brown well construction information 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/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:
SUBMITTAL INSTRUCTIONS
QQ�
9.Total well depth below land surface: I D (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdVerent(example-3@200'and 2@1005
construction to the following:
10.Static water level below top of casing: (a (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: ‘ (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
` C" above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: /4)fZ ,i7/ '/
(i.e.auger,rotary,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: 7;r G h 1r 24c.For Water Supply&Infection Wells: In addition to sending the form to
� i the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: t Amount: d completion of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016