GW1--03508_Well Construction - GW1_20230519

MTLL CONSTRUCTION RECORD(GWr 1) Print Form
For Internal Use Only:I.Well Contractor Information:
Chris King
well ContractorName 14.WATER ZONESFROM TO DESCRIPTION
2080-A qt ft a M 3
NC Well Contractor Certification Number ft. ft.
Aqua Drill, Inc. 15.OUTER CASING(for multi-cased wclls OR LINER a licable
FROND TO DTAniIiIEIt THICKNESS MATERIAL
CompanyName Q ft. ft �Si in. t /-�`-
J(p5 u Z� 16.INNER CASING OR TUBING eothermal closed-loo C�
2.Well Construction Permit#• l FROM TO DtARSG'1ER List all applicable well construction permits(i.e.UIC,Coung;State,Variance,etc) ft. ft. in. TffiCKNESS MATERIAL
3.Well Use(check well use): R. ft In.
Water Supply Well: 17.SCREEN
Agricultural FRO51 TO DIAMETER SLOTSTU THICKNESS MATERIAL
�Municipal/Public ft. it. ia.
Geothermal(Heating(Cooling Supply) okesidential Water Supply(single)
Industrial/Commercial ft ft W.
[]Residential Water Supply(shared)
lrri ation 18.GROUP
Non-Water Supply Well: FROM TO nrATERrAL EMPLACEMENT METHOD it &AMOUNT
ft•
n Monitoring :Recovery C t�
Injection Well: R• ft
Aquifer Recharge DGroundwaterRemediation ft. ft
Aquifer Storage and Recovery oSalinity Barrier 19.SAND/GRAVEL PACK ifa ]icalrle
._. Aquifer Test FROM TO nrATERTAL EMPLACEMENTMETHOD
�StormwaterDrainage ft ft
Experimental Technology oSubsidence Control
fG ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necess Geothermal enting/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soWrock a rain size,eta)
C) ft. fL C/ ,
4.Date Wells)Completed•.5— .3 Well ID# 3 It ft. f
5a.Well Location: fitV z(3�
% '• t3 u� tz Qitll�e
fL fL
Facility/OwaerName Facility ID#(if applicable) It. ft
2 7 ,ry . N C f 1 t.�y�� fz ft
Physical Address,City,and Zip °�_
MARKS 'a aQ.\.1 �.--a 0. .,.:.
County n '1
Parcel Identification No.(PIN) Vim, t
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 17
F l f i(if well field,one lat/long is sufficieat)
22.Certification: j;!+•I'�j r3'J�
O6.Is(are)the well(s) manent or Temporary SignatmeofC tSedWeltCo ^cror
Date
7.Is this a repair to an existing well: �y¢s eP`wall construction it By signing this fornb 1 hereby certify that the irell(s)was(were)constructed in accordance
If this is a repair,fill out/along formation an lain the Hahne ofthe copy ofthis cord has be0e0iror ISif NCAC 01C.OZ00 Well Construction Standards and that a
repair under#11 remarks section or on the back of thirfornr Provided to the well ai»ter.
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 I GW 1 is needed. Indicate TOTAL NUMBER of wells
drilled. construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface:_
SUBMITTAL INSTRUCTIONS
For multiple weiLr list a!1 depths if different(example-3@200'and2@100) ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing:
to the following:
sing:�d�
Ifrroterlevel is above casing,use";^ (ft) Division of Water Resources,Information Processing Unit,
11.Borehole diameter: (in.)
1617 Mail Service Center,Raleigh,NC 27699-1617
H 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Wed!construction method:�]I z L' r7_h i � above,also submit one copy of this form within 30 days of completion of well
(Le.auge,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
132.Yield(gpm) Method of test:S s/"+i 11�_
24c For Water Sunply Sc Iniection Wells: In addition to sending the form to
13b.Disinfection type Amount:C� the address(es) above, also submit one copy of this form within 30 days of
Z completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina De
partment of Environmental Quality-Division of Water Resources
Revised 2-22_2016 ,