GW1-2023-02479_Well Construction - GW1_20230404

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WELL CONSTRUCTION RUCTION RECORD(GW 1) For Internal Use Only: Print Form
1.Well Contractor Information:
Chris Kin
g
14.WATER ZONES
Well Contractor l\TemC FROM TO DESCRIPTION
2080-A ;2gCa' f ft 6-i Pt
Pri
ft.
NC Well Contractor Certification Number ft.
Aqua Drill, Inc. 15.OUTER CASING(for multi-cased wells)OR LINER(if ap !feeble)
FROM TO 16Vg DIAMETER THICKNESS MATERIAL
ft. a ft;
Company Nariue ® 443 in. Li
3 g fil ��
�°�) 9 16.INNER CASING OR TUBING(geothermal closed-loop) Ci
2.Well Construction Permit#:') / �3 U C (yj i2 3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UK',Couniy State,Variance eta) ft. ft. in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN
AgriculturalFROM TO DIAMETER 'SLOT SIZE THICKNESS MATERIAL
OMtmicipal/Public ft. fr. in.
Geothermal(Heating/Cooling Supply) ,rResidential Water Supply(single)
Industrial/Commercial ft' t°'
Residential Water Supply(shared) 18.GROUT
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 2 a
Monitoring C ft :20ft M3ir2i'�/bi�C ��t` )�
Recovery ft ft 7
Injection Well:
Aquifer Recharge DGroundwaterRemediation ft. ft.
Aquifer Storage and Recovery 0Salinity Barrier 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OlTracer 20.DRILLING LOG(attach additional sheets if necessary)
TO DESCRIPTION
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM (color,hardness.solUmektype grate slz�eta)
0 ft' /0 ft 5c ir-1, S'a4,1, rl 12 0 c/e 4.Date Well(s)Completed:3 17 23 Well ID# It. 3 ft
5a.Well Location: ft. ft.
Facility/Owner Name Facility DV(if applicable) ft f.
ci 5 95 !'\ tJ C ci 7 j-44,.e ft.
ft p•°" ') '¢ 2023
Physical Address,City,and Zip ft ft
i4 aI'vtn®8)'C e 21.REMARKS I1t`i•i:r:x 4 1 �i��OC . (:t ;l
County 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 'on:
N w
e
6.Is(are)the well(s) Permanent or OlTemporary Signature ofCeaified 1vellC33
�hact'or @ A�� '�
7.Is this a repair to an existing By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
P well: ftYes or / a with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair•,fill out known well construction Information and explain the nature oft he copy of this record has been provided to the well owner.
repair under#21 rematis 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
9.Total well depth below land surface: 32 5'7 ( )
For multiple wells list ail depths i([different(example-3Q200'and 2QI00� 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: C) (ft.)
Ifwater level is above casing use"+' Division of Water Resources,Information Processing Unit, •
�/ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)
24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: /4 l d'� j�l above,also submit one copy of this font within 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc) 4 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: pc 1 - 24e.For Water Supply&Injection Wells: in addition to sending the form to
13b Disinfection type:d �!'I Amount / 0the 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.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016