GW1--04398_Well Construction - GW1_20230707

Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I Print
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A a© ft' a( rr. s �r ,Pi
NC Well Contractor Certification Number on ft-( I 6 t�(
15.OUTER CASING(for mull-cased wells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS I MATERIAL
Company Name D ft (/3 ft. j`�7Sl in. €t 52 6�1t1
3 ! ,��� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 7G w p2 5 FROM TO DIAMETER _' THICKNESS MATERIAL,
List all applicable well construction permits(i.e.UIC,County,&ate,Variance,etc.) ft• ft in.
3.Well Use(check well use): ft ft. tn.
Water Supply Well: 17.SCREEN
• FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
in.
Agricultural DMunicipal/Public ft, ft.
Geothermal(Heating/Cooling Supply) ,Residential Water Supply(single) ft ft in. I
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
/1 ft. ft. I7�jl;•1C �ri p f•
Monitoring Recovery ( J ft.�7Clr) ft. J l�
Injection Well:
ft ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable),
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL l EMPLACEMENT METHOD
Aquifer Test (jStormwaterDrainage ft ft
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) f Tracel 20.DRILLING LOG(attach additional sheets if necessary}
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,gain size etc.)
/ 9 J �, ft /, ft �c IC I � l
4.Date Well(s)Completed:(A' 1 3 Well ID# L ) r y ft. (_,ls ft. Isigttr d i '7 ock rI —
5a.Well Location: 3 5- ft �,25-tt. $)s c r ca n1,;; - Sigrid iZoC/�
ft. d�,C ft f CS
Facility/Owner Name Facility ID#(if applicable) ft. ft _ 1b rt h' "' i)
CI1l b j.o i7C� fiinfd.e-ewS r( ft. ft 1 - __
Physical Address,City,and Zip rt. ft J;.iI 1 l u l
I-A r ii 21.REMARKS
otmty Parcel Identification No. Pun ifl,-,-;i ,47 f�a;-.Fr.-::g.,x-,..3.' U nx
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W ( � - 9-o23
6.Is(are)the wells) ermanent or I�Temporary ignature of Certi ed Well tractor Date
By signing this form,I hereby cert fy that the,well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: JJYes or tigNo 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:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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: ( ) 24a.For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths It-different(example-3@200•and 2@100') construction to the following:
10.Static water level below top of casing: �O (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: Cd (in.) 24b.
24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: /f 7 (�It.,i 'i above,also submit one copy of this form within 30 days of completion of well
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) 16 Method of test: . S)4 24c.For Water Supply&Infection Wells: In addition to sending the form to
f C the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: ti f' Amount: C d 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