GW1--03168_Well Construction - GW1_20230505

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WELL CONSTRUCTION RECORD(GW-I) r
I Internal Use Only:
I.Well Contractor Information:
Chris King 14.WATER ZONES
Well ContrctorNamo FROM TO DESCRIPTION
2080-A f J
ft. ft.
NC Well Contractor Car tificationNumber
15.OUTER CASING for multi-asad wells OR LINER tf a licable
Aqua Drill, Inc. FROM TO I DIAMETER THICKNEss I MATERIAL
fL � fr. 5/ �• 7
Company Name e t
�^�' 16 INNER G ORTUBING euthermal closed loo
2.Well Construction Permit#:-/ FROM TO DIIETER THICKNESS MATERIAL
List all applicable aril construction permits(I.e.UIC,Coturh;Statg Variance eta) ft. ft
3.Well Use(check well use): ft. ft. In.
Water Supply Weil: 17.SCREEN
FROM TO I DIAMETER I SLOTSIZE THICKNESS MATERIAL
Agricultural nMunicipaMblic % fL in.
Geothermal(Heating(Cooling Supply) Okesidential Water Supply(single) ft. is
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
litigation FROM TO MATERIAL E4IPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: a & fe
ft i
Monitoring !- Recovery ft ft.
Injection Well:
Aquifer Recharge ft ft.
q g i�GroundwaterRemediation
quifer Stooge and Recoveryl 19.SAND/GRAVEL PACK if applicable)
L6'SalmttyBamer FROM TO MATERIAL EMPLACENIENTMETHOD
Aquifer Test OStormwater Drainage ft• ft
Experimental Technology OSubsidence Control f4 IL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if noes
Geothermal(Heating(Cooling Rdut `—). Other(explinund.,#21 Remarks) FROM To DFseIDPttox(color,hardnm solUmck ty
a rain size etc
ft. ff: r a
4.Date Wells)CompletedA/_.')'- �Well II)# �; ft'
- t s. ,1 z a jlr
5a.Well Location: , ft' �1 IL fk{
ft. ft.
Facility/OwT aerName Facility IN(ifapplicable) [t fr. K
1 S (z 17, 12 J 811sbaeti f-'Yt�'
PhystcalAddress,City,and Zip �31 ft. is MAY 9 v 2023
' k)\M 21.REMARKS r
County Parcel IdentificatlonNo..(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(ifwell field,one latllong is sufficient) 22.Certification:
w
6.Is(are)the well(.) tPermanent or 0Temporary Sigoature of6rfified WeltContractoi Date
By signing this form,I hereby aertij5,that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or ONO with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Wdl Construction Standards and that a
Ifthis is a repair,fill out krrouvt well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on fire 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 ifnecessary.
drilled:
SUBMITTAL INSTRUCTIONS
For multiple wells lust all depths ifdiQererrt
9.Total well depth below land surface: r (fL) 24a.For All Wells: Submit this form within 30 days of completion of well
(example-3/@200'and 2@l00� construction to the following;
10.Static water level below top of casing: la 6 (ft) Division of Water Resources,Information Processing Unit;If water level is above casing,use"+" $ t,
(/p I617 Mail Service Center,Raleigh,NC 2 769 9-1 61 7
11.Borehole diameter: (in.) 14b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: f (�iZ 1 �1 above,also submit one copy of this form within 30 days of completion of well
g rotary,cable,direct us etc. construction to the following.{i.e.auger,,ro e, push, )
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Matz Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)_- j r Method of test: 24c.For Water Supply&Infection Wells: In addition to sending the form to
r� the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: Amount 'f 2 completion of well construction to the county health department of the county
where constructed.
E Form GW-7 North CatativaDepartment ofEnvironmental Quality-Division of Water Resources Revised 2-22 2016