GW1-2023-02221_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
FROM TO DESCRIPTION
Well Contractor NameFROM 2080-A L ft. 15/ �ft 2 U, I i>i �
ft. ft.
NC Well Contractor Certification Number I5.OUTER CASING fur multi cased webs OR LLYER if a livable
Aqua Drill, Inc. FROM TO D4AMETEIt THICKNESS MATERIAL
t. ��} ft. in.�
Company Name f � ,50,0,2 1 �-'i L)
�7 L f 16.INNER CASING OR TUBING( ea thermal closed-loop)
2.Well Construction Permit#: / FROM TO DIAMETER_ THICKNESS MATERIAL
List ail applicable well construction permits(i.e.UIC County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft h
Water Supply Well: 17.SCREEN
FROM TO DIAMETER CLOT SIZE THICKNESS MATERIAL
A&icultural Municipal/Public ft ft. ia.
Geothermal(Heating(Coohng Supply) residential Water Supply(single) ft. ft, in.
Industrialt'Commeraial DResidential Water Supply(shared)
18.(:ROUT _
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. C
Monitoring Recovery fa ft.
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if a licanlel
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
!Aquifer Test [3Stormwater Drainage ft. fL
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additionsd sheets if necessary)
FROM TO DESCRIPTION(colon hurda-%soi1l—k e, ruin size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under 921 Remarks) .7) --
ft
ft.
4.Date Well(s)Completed:�c/�=' 3 Well ID# ft• ft•
5a.Well Location: ,ft' y 6 IL G" S h L' 1
3' L� It
2 r� C
iFacilility`/Owner Name Facility iD#(ifapplicable) ft. "ft J -) Z �'
Physical Address,City,and Zip fi4 ft.
V 1`�s 21_REMARKS
County Parcel Identification No.(PIN) _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —
(ifwell field,one iaVlong is sufficient) 22.Certifi• tion:
6.Is(are)the w'ell(snPermaneat or Temporary Signature ofCerti ed Well Con"clur Date
By signing this form,1 hereby certify that Me xell(s)xas(were)constructed in accordance
7.Is this a repair to an existing well: C)Yes orL12fNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Siondards and that a
If this is a repair,fill out brown well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis form.
23.Site diagram or additional welt 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 I GW-1 is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages ifnecessary.
drilled:
G SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:_ (N (ft-) 24a. For All Wells: Submit this foam within 30 days of completion of well
For mulnvle wells list all depths ifdii ferew(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
I(safer level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 2 7699-1 61 7
11.Borehole diameter: K (in.) 24b.For Injection Wells: in addition to sending the form to the address in 24a
7 S7 I above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: /tt f�t construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Iniection 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: Tl� Amount: ;2 completion of well construction to the county health department of the county
where constructed.
i:otm GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016