GW1--03597_Well Construction - GW1_20230522

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES- ; ,i
Well Contractor Name FROM TO DESCRIPTION I
ri
2oso-A 7b 1L 7 ft 1
ft ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased'wells OR LINER If a lieatile
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL.
Company Name v ft 3 ft / IT in. 11,59
IG �a
'-16i INNER CASINGORTUBING" eotbermalclosed-loo _
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) % ft in.
3.Well Use(check well use): ft ft In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public . ft. ft in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft is
Industrial/Commercial E21tesidential Water Supply(shared) '18.GROUT
lrri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ® ft. o it `2 ti
Monitoring CIRecovery ft ft
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery OSalinity Barrier FROM I To I MATERIAL EaiPLACEi%IENT METHOD.
Aquifer Test OStomrwater Drainage ft R.
Experimental Technology OSubsidence Control ft ft
Geothermal(Closed Loop) OTracer '10.DRILLING.LOG attach additional sheets if necessa")
`-Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION color,bardness,soivrock tyye,grain size,etc.)
a Q ft. ft
4.Date Well(s)Completed: S �� Well ID# ft. ft. S d ty C j -
5a.Well Location: ft i�sue' Uc. iZ iA
ft ft
Facility/Owner Name Facility]IKl(if applicable) 2 ft L:4 ,'of 3` ,y y�
ft. MAY
J
Physical Address,City,and Zip ry,C X7 f 3 ft- ft.
'.21.REMARKS. -.County Parcel Identification No.(PIN) �j• ��' ,1 r"
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(Twell field,one latnong is sufficient) 22.Certification: C )
6.Is(are)the well(s) ermanent or [3Temporary Signature ofCertified Well Contractor Date
!!l���``` By signing this form,I hereby certify that lite wells)vras(were)constructed in accordance
7.Is this a repair to an existing well: DYes or io with 15A NCAC 01C.0100 or 15A NCAC 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 thEv record has been provided to the well owner.
repair under#21 remarla 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 ifnecessary.
drilled: f SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �/ 5 (ft) 24a. For All\Veils: Submit this form within 30 days of completion of well
For multiple wells list all depths lfdifferent(example-3``@200'and 2Qa 100) construction to the following:
10.Static water level below top of casing: C Q (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: )4 1'17_ J IZ 1 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) e Method of test: s iC 1—} 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
13b.Disinfection type: T Amount: completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016