GW1--04370_Well Construction - GW1_20230707

1
PrintForm,
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only,
1.Well Contractor Information:
Chris King 14.WATER ZONES' .
Well Contractor Name FROM TO DESCRIPTION
2080-A l3S•-ft. 13G. ft. .2St✓///l'i _
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licabie) . -
Aqua Drill, Inc. FROM TO //DIAMETER, THICKNESS MATERIAL -- --
Company Name G
0 ft 6 5 fL Co-i in. t/83S GA 1 1 t/
_ 16.INNER CASINORTUBING(geotliermal'closed-loop). .
2.Well Construction Permit#: t✓/r.S 7of Pt/9,2 FROM TO DIAMETER i THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,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 ft. ft. in.
Geothermal(Heating/Cooling Supply) d Residential Water Supply(single) ft. ft in.
Industrial/Commercial QResidential Water Supply(stared) 38.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft: I. 1ti.hv,f tI4;1
Monitoring °Recovery ft. ft.
Injection Well:
ft ft
Aquifer Recharge °Groundwater Remediation
19:SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery EISalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IStormwater Drainage ft. ft.
Experimental Technology IOSubsidence Control ft ft
Geothermal(Closed Loop) {Tracer "20.DRILLING LOG(attach additional sheets if necessary). .
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM - TO - _DESCRIP110N(color,hardness,sail/rack type grain s ze etc.)ft. 6 ft- tzrd et�y
re)
4.Date Well(s)Completed:4 S'.2 S Well ID# - - - 6 ft- S� ft 5 pjvd )ZG ce
5a.Well Location: 5-5-- ft q.2�ft fl/uc 6)Z `{,C
�\ k ft. F ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. $ ?{m .'L..s iv ;1"..:Li.
ft�1 3 jvt foe .2 13u�1;ivg40to IQ .G JIJ1 a 7 2021
Physical Address;City,and Zip
��MI/��/E� 21.REMARKS li;f.^.i rr.: .il f'crr.:,t`itghi*:.QJ Lira ,
County Parcel Identification No.(PIN) .°:04h..Ett`3 e
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W ( 4 �3
6.Is(are)the wells) Rermanent or (Temporary Signature of Certified Well ntractor �dte✓
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ]Yes or ONo with ISA NCAC 02C.0100 or ISA 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2^Z S- (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths'ifdifferent(example-3 ,200'and 2@100) construction to the following:
10.Static water level below top of casing: j' (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: CJ- (in.) 24b.For Infection 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/ z. (421 l! construction to the following:
(Le.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) J Method of test ljlq 1l•-I- 24c.For Water SuDnly$c Injection Wells: In addition to sending the form to
'1 n� • the address(es) above, also submit one copy of this form within 30 days of
13b I7.Disinfection type: r 14 Amount:! ©e _- . 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