GW1--04383_Well Construction - GW1_20230707

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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 1‘0ft- /(r f /5-' 6tt'/✓-7
R. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name (. ft• ei , ft• 6N (n, r�C 6,A 1 4J
t� 16.INNERCASING OR TUBING(geothermal closed-loop) A/
2.Well Construction Permit#:9/D 3(�air f, ,3' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UK',County,S te,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 9Municipal/Public It. ft in.
Geothermal(Heating/Cooling Supply) a2esidential Water Supply(single) ft. ft in.
Industrial/Commercial QIResidential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q n. .20 n
Monitoring r3Recovery ft. ft
Injection Well: l'LYl�9 �OCIC.
ft. ft.
Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL'PACK(if applicable)
Aquifer Storage and Recovery QSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft• ft
Experimental Technology °Subsidence Control ft. ft.
Geothermal(Closed Loop) °ITracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,sai0rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) ilOther(explain under#21 Remarks)
/`�(� d ft. 9 ft /Zcd (6/4 y
4.Date Well(s)Completed:6 -,2.3 Well ID# 3 ft 3�"" ft. .5-ArT/< ' i- O C tC
5a.Well Location: t� -iP 3-� ft �-ft glue
6 iz (\ C
sill 17_e } 00 itdazc ft. ft /J }
Facmtity/bwnerName Facility ID#(if applicable) ft. ft ,""'I ?' ri, p e.-,,.
ft, ft. f 'n?-_.Le j>.,,i V r !
ftPhysical Address,City,and Zip I(l l A 7 'f 9'l
�q 21.REMARKS
' .11
S /91 iIwe Iflia;s o1.3JC7 :�f :'3;C+ I!Ws
Parcel Identification No.(FIN)
DI O 30G
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:N W .7:,„: lO/
- C --i
6.Is(are)the well(s)efPermanent or QTemporary cure of Certified ell Conti for Dace
By signing this form.I hereby certify that the we11(s)was(were)constructed in accordance
7.Is this a repair to an existing well: IJYes org3No with 1SA 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:
S.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: „,2,2$' (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(200•and 2@100) construction to the following:
10.Static water level below top of casing: 3( (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: ( (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
1/L t / above,also submit one copy of this form within 30 days of completion of well
/12.Well construction method: / l" 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) / Method of test 51 Cs),-1. 24c.For Water Supply&Infection Wells: In addition to sending the form to
type:
�� J the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection a' Amount:Q 0 'Z 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