GW1--04367_Well Construction - GW1_20230707

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only: Print Form
1.Well Contractor information:
Chris King 14.WATER ZONES -
Wcll Contractor Name
FROM TO DESCRIPTION
2080-A ion R. /aa 3o Gt�.P-�
R. R.
NC Well Contractor Certification Number
Aqua Drill,inc. 15.OUTER CASING(far multi-eased wells)OR LINER llf ap Iksbte)
FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft j/3 ft. %YCI in. • /g3 _1 J iVij
�5 Z/�C/6t f, 3 6. NEA CASING/V OR TUBING OiAM(geothermalC doted-loop)
2.Well Construction Permit#:S[4 C .f. FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Slate.{Parlance.eta) ft. IL In.
3.Weil Use(check well use): R. ft. In.
Water Supply Well: 17.SCREEN
A CUItUrdl FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OMunicipal/Cublic R. R. In.
°Geothermal(Heating/Cooling Supply) t residential Water Supply(single)
R rt. In.
°Industrial/Commercial raResidential Water Supply(shared) - -
18.GROUT
'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0Non-Water Supply Well: �1 IL02 d f6 /3 eilJ/,r,i Tk C.h 4S
Monitoring °Recovery �/ R. a. J
Injection Well:
Aquifer Recharge °Groundwater Rcmediation ft n
°Aquifer Storage and Recovery °Salinity Barrier 19.SAND/GRAVEL PACK(If applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test QSlonnwater Drainage R. ft
°Experimental Technology °Subsidence Control R. ft
°Geothermal(Closed Loop) OlTracer 20.DRILLING LOG(attach additional sheets if necessary)
°Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks).. FROM TO DESCRIPTION tcelor.bordaeu wWmek type.Rita aim tin)
, <� ft- g it.
fie e 1 e y
4.Date Well(s)Completed:tC 9.2J Wel1 ID# kc T V it. 60 It l,I d etc&
Se.Well Location: C R. 9 S rt. in u i
5)4 r e(,,n w
a cis LoAcS do Lir 96 ft. (yg"ft /3k cc G,z.4w;.,7 c.
Facility/OwnerName Facility IDN(if applicable) R. rt.
ft. f��3� i N C �2
. -y =.�T.s' ;il
Physical Address,City,and Zip ft ft.
/t/1 .CC21.REMARKSI'i t 9 7 10134//9/Vty /Y
Parcel Identification No.(PIN)
Sit.Latitude and longitude In degrees/minutes/seconds or decimal degrees: D f -vm tea_?
' (if well field,one lar/long is sufficient) 22.Certification:
N_ tyy
e
6.is(are)the weli(s)6Permaaent or Temporary Signs ofCersrti WollConvactorl ��
By signing this form,I hereby certify that the well(a)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or el2f.No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Olds it a repair,JIiI out iaolta well construction Information and explain the nature of the copy of-this record has been provided ro the well otvner.
repair under k21 remarks section or on the hack of this form.
23.Site diagram or additional well details:
S.For Ceoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or will
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
(� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: l ,- (ft.) 24a. For All Wells: Submit this form within 30
For multiple t+elt list all depths ifdifferent(example-3 ,00'and 2Qa 10D) days of completion of well
construction to the following:
10.Static water level below top of casing: 3 tJ (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.use"+"
1617 MaU Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: C ()n.)
246.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: 4/R d JZ i 11 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,
22 1636 Mall Service Center,Raleigh,NC 27699-1636
13e.Yield(gpm) .1 Q Method of test:S z Ql h.-*- 24e.For Water Supply&infection Wells: In addition to sending the form to
13b.Disinfection type: T + ressts) above, submit one copy of this form within 30 days of
{ '� Amount: Z completiontheadd (
of well construction to the county health department of the county
i where constructed.
1
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resource;
Revised>__> -�2_t)tei