GW1--04371_Well Construction - GW1_20230707

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WELL CONSTRUCTION RECORD(GW-f1 For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES ti
Well ConnactorName FROM TO DESCRIPTION
2080-A )36 f• 131 0. JO �-1, Pt r^-
NC Well Contractor Certification Number / 0 R. fo t 1 t
15.OUTER CASING(for multi-cased wefts)OR LINER ap linable)'
Aqua Drill, Inc. - FROM TO DIAMETER THICKNESS MATERIAL
�
Company Name r/,, d ft L ft j�s-in. t f. 6 A l i
2.Well Construction Permit#: 5-6 d. "1" & D FRO6. M
CASING OR TUB DIAMETER(geothermal
THICKNESS, MATERIAL
List all applicable well construction permits(i.e.UIC,Comity State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): IL ft. to.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural °Municipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) dResidential Water Supply(single) ft, ft. in.
Industrial/Commercial °Residential Water Supply(shared) <18.GROUT -
' Irrigation FROM TO MATERIAL.. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. )0 ft- .2__0-)wee (b 1 ( p S
Monitoring , --.-,,. S� Icovery ft. ft. �r l Lc( /.Y--
Injection Well:' :a 1.., 5 V L., .
Aquifer Rech "4"'�s s R. ft.
Aqu ge Ili Groundwater Remediation
19.-SAND/GRAVEL PACK(if applicable):
Aquifer Storage and BeCov ,7 202 Ia1SalinityBarrier FROM - TO MATERIAL.- EMPLACEMENT METHOD
Aquifer Test JJ��J- I*1 Qrmwater Drainage ft. ft.
Ex enmental> dm,olp&� ,• MI Subsidence Control R. it.
Geothermal(Closed Loo • °Tracer 20.DRILLING LOG(attach additional'Sheets,if necessary)
Geothermal(Heating/Cooling Return) !Other(explain under#21 Remarks) PROM TO DESCRIPTION(color,hardness.son/cork type grata she etc.)
/' rel r ,, �( ® ft. 4 ft i�Ze-d 1 y)`
4.Date Well(s)Completed:CO i_i' 2 3 Well ID# ` o'r V ( ft. )% ft. r >G is
5a.Well Location: I S it 1 r )0e 6Effi 1;)-e
&WN-$C) Z 'li/ld c34,wt�eiti c ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
52)i )al lemi weesd$ (fit ft ft.
Physical Address,City,and Zip ft it.
416' A)Cr 21.REMARKS .
County Parcel Identification No.(PIN) 722 p 86 C i 6 4'l-ic)t. 17i7 d ilzC3,Ai .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) ,22.Certifi on:
N W 1/c47'z ~ 23
6.Is(are)the well(s) ermanent or Temporary Signature ofC "Con for D to
By signing this form,I hereby certify that the we (s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or{ TO with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair, out known well construction information and explain the nature ofthe 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: 1 g5- ( ) 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: 2 C' (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: 6 (in) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12 Well coastraction method: IIj - above,also submit one copy of this'form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,eta) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm). Method of test 5 i e Vci li i- 24c.For Water Supply lit Infection 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: �� Amount: 0 - completion of well construction to the county health department of the county
where constructed. -
Form OW I North Carolina Department of Environmental Quality-Division of Water Resources I ! Revised 2-22-2016
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