GW1--03510_Well Construction - GW1_20230519

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WELL CONS I. UCf$®lit RECORD(cw ) For Internal Use Only.
1.Well Contractor Information: •
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A A? fit z 9/ it.
.2 i A/rL
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-eased wells)OR LINER(if ap Iicable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 4.:::), ft. 2 C/ ft. %• 5.4 in. i 1. 0 /J"f9 h
�� S �6z-V 2-) 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: .7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.CIIC,County.State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ff. ft in.
Water SupplyWell: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
;Agricultural oMtmicipal/Public ft. ft. in.
*Geothermal(Heating/Cooling Supply) gettesidential Water Supply(single) ft ft in.
It Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Cr� fit..20 fit 13*I 11.1 7)0 t k i f f
;Monitoring DRecovery ft. ft
Injection Well:
ft. fit*Aquifer Recharge �G mundwater Remediation allAquifer Storage and Recovery Salmi Barrier 19.SAND/GRAVEL PACK(if applicable)
ty FROM TO MATERIAL EMPLACEMENT METHOD
*Aquifer Test 0 Stormwater Drainage ft ft
ii Experimental Technology OSubsidence Control ft. ft.
*Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
*Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ,FROM1f TO DESCRIPTION icalu,hardness,saatmctc tn,e grata size etc)
4.Date Well(s)Completed:J 'l,2-2 Well ID## 3 D- c fwIDir to .
5a.Well Location: 6 d ft. C/,7 - ft- 0l hie- 6 iiZ i/tKj p i 4 r_
ft. it l c.
rp
t� pp R3rp
Facility/Owner Name Facility ID#(if applicable) ft ft b00 a..,,
•
`Sc�33 �'V Ai 62 ft. ft. MAO' 1, 9 2023
Physical Address,City,and Zip ft. ft.
Aip
lit li/Ce- L S'� Z1.REH51iRICS 1 ' .eew. -. �Ur-..
V.v lfti'.S_`.r`.t7
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient) 22.Certification:
N W -
a 2 S�-lz-.33
6.Is(are)the wells) ermanent or tj. Temporary Signature of ertified Well ntracror Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ONo with ISA NCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
v SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / 2< (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
A:win up/a wells list all depths ifel fferent(example-3Q200'and 2(§10D')
construction to the following:
10.Static water level below top of casing: 'O (ft) Division of Water'Resources,Information Processing Unit,
ifwater level is above casing,else`+/^ 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 I (Z l above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,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
13a.Yield(gpm) 2 Method of test: 5 r C1J}- 24a For Water Supply&Injection Wells: In addition to sending the form to
�( the address(es) above, also submit one copy of this form within 30 days of
1311.Disinfection type: H T Vl Amount: /(e 0 Z., 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