GW1--03509_Well Construction - GW1_20230519

WELL CONSTRUCTION REColti➢(G�l� Print Form
For Internal Use f?nly:
I.Well Contractor Information:
Chris King
11,WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A ft
't
NC Well Contractor Certification Number ft. p;
Aqua Drill, Inc. IS.OUTER CASING formuld.casedwells OR LINER(if a ucable
FROM TO DLIMETER THICKNESS MATERIAL
Company Name ft. Sy0 % S/� ia.
s
16.INNER CASING OR TUBING(geothermal closed-loan)2.Well Construction Permit ,:, S .�, �, (� ,� FROM To DIAMETER THIciQVESS MATERIAL
Lisl al[appflcable uel[construction pernuts�.e.U1C,Coun Stag Parlance,eta) ft ft in.
3.Well Use(check well use): ft. ft In.
Water Supply Well: 17.SCREEN
Agricultural ElMunicipal/Public FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
fr
Geothermal(Heating/Cooling Supply) residential Water Supply(single) fr. . in.
Industr avCommerciai tt• ff ia.
Residential Water Supply(shared)Irri 18.GRO
Non-water UT
te &Supply We1i: FROM To MATERIAL EMPLACEMENT METHOD AMOUNT
Non-
Monitoring ' Recovery ft. S
Injection Well: fr
Aquifer.Recharge DGinundwaterRemediation ft
Aquifer Storage and Recovery OSalinity Bier 19.SAND/GRAVE pACK(if applicable)
FR0it TO. MATERIAL EMPLACEMENTMETHOD Aquifer Test oStormwaterDrainage ft. ft.
Experimental Technology oSubsidence Control fr, fe
Geothermal(Closed Loop) GDTracer 20.DRYLLING LOG attach additional sheets if nec
Geothermal(Heating/Coolimg Return) '. Other(e lain under#21 Remazks) M To DESCRIPTION(color,hardness soll/mek a groin size,ere,
-fir ft ,� .
4.Date Well(s)Completed: - ,2 Well ID# - R. ft.
Sa.Well Location: _72(� 52
"
ft. th
Fability/Owner Name Facility lD#(if applicable) fG ft
Physical Address,City,and Zip ft MAY
county i v raHw•:�.i fSl
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: C 3 1;M10 I'm
(if well field,one latllgng is sufficient)
22.Certific 'on:
6.Is(are)the wellwz&rmanent or Temporaryblgmmrc of Cecti ed Wdl Contract(V Date
7.Is this a repaii to an existing well: XeS pr By signing this jornr,1 hereby cerayi that the nell(s)ivas(were)constructed in accordance
o ivith 15A NCAC 02C.0100 or 15A NCAC 02C.0100 lf'e11 Construction Standards and that a
If111is is a repair,fill out/arolvn well carutruction tr formation and explain the nature of die Copy of this record has been provided to the well owner.
repair rmder#21 remarks section or on the back of ffill
23-Site diagram or additional well details:
8.For Geoprobe/iDPI'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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBIVfITTAL INSTRUCTIONS
9.Total well depth below land surface:),2 5
For multiple wells list all depths iif different(example-3 a200'and 2@1001 00 24a.For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Ijivaterlevel it above casing, ise
10.Static water level below top of casing: �0 (ft) Division of Water Resources,Information Processing Unit, -
r "+"
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:�� t jZ [y Z t I above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) 1 F---� 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/�i.01114_ 24c.For Water SuMly St In Wells: In addition to sending the form to
13b.Disinfection type: . Amount I { the 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 GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016