GW1--04369_Well Construction - GW1_20230707

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WELL CONSTRUCTION RECORD(GW Y) For Internal Use Only: -
1.Well Contractor Information:
Chris King
14.WATER ZONES.
Well Contractor Name FROM TO DESCRIPTION
2080-A %"U n• .29/'ft ., CI1 fin.
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-rased.wells)OR LINER(if ap livable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name a ft. Li 1 ft (S/e in. , f S tl5 /
s- 1 � 16.INNER CASING OR TUBING(geothermal closed-loop) ,
2.Well Construction Permit#: 5 4 a 3 ci e'A.k.) .23 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Comity,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
- FROM TO DIAMETER SLOT SIZE THICKNESS - MATERIAL
Agricultural OMunicipal/Public tt ft _ in.
Geothermal(Heeting/Cooling Supply) irliResidential Water Supply(single) Eti ft. in.
Industrial/Cotnmercial °Residential Water Supply(shared) 18.GROUT" . -- -
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: V ft.
.4
ft 3-�i�5 Je d k'tJ S
Monitoring 0Recovery ft. ft. /
Injection Well: 1.`�
Aquifer Rechargeft ft
q �IGroundwaterRernediation
Aquifer Storage and Recovery Salini Barrier 19.SAND/GRAVEL PACK(if applicable) . .
ty FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology °Subsidence Control ft. ft.
Geothermal(Closed Loop) I❑ITracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUroektype groin size,etc.)
// 0 ft. 6 ft / ed di yam y
4.Date Well(s)Completed:( -6-mg 5 Well m# s6v ft 2e ft 5'1(-ji d o c lc
Sa.Well Location: o[© R• 32 • 1310c 6l2A�i+c
� lrhe5 IeRIZiwq ft. ft
Facilityy//Owneerr Namee ft.
J�J O /Z/l Facility 1D#(if applicable) ft' pSQ/✓ %vt i�� ft. ft p4 ,.....
Physical Address,City,and Zip[ ft ft is Q ;L�i p i r'-a
/Ai'ql$1/lJe 21:REMARKS v+' . A 5
County Parcel Identification No.(PIN) JUL7 1 U 0 ?n,3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: l g -:--''_ �-
(if well field one latllong is sufficient) ""D ' :;-..›tier:;'g a niA
22.Certification: D11; •l00 I
N W
eAny �')'- 6 =is--23
6.Is(are)the well(s) ermanent or °Temporary Signature of Cemfieil we ntracto Date
By signing this form,I hereby cerhfy.that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes oreEko with ISA NCAC 02C.0100 or 15,4 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 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:
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 if necessary.
drilled:
P ��� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdifferent(example-3@200'and 2@700) construction to the following:
10.Static water level below top of casing: SC (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing use '+ 1617 Mail Service Center,Raleigh,NC 27699-1617
/
11.Borehole diameter: �o (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: Mil /Li l 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 27699-1636
13a.Yield(gpm) 3 Method of test:' tr}h-k. 24c.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: Ft7 T l4 Amount: i/(Q 0 2- 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