GW1--04988_Well Construction - GW1_20230807

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WEAL CONSTRUCTION RECORD(GW-.11 For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080 A 3 cO lift. 2 Cf) tt. 20 4 1 Y' r l-
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER Ofap IImble)
Aqua Drill,Inc. FROM ft 6 TO DIAMETER THICKNESS MATERIAL
Company Name 0 , 6 " 6119 i° SOiz,z 1 ei 1! cc
) 16.INNER CASING OR TUBING(geothermal closed-loop)
Z.Well Construction Permit#: e4 ��d��yy FROM TO DIAMETER 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
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Sn °Municipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) jErgesidential Water Supply(single) it ft la.
Industrial/Commercial DiResidential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: CJ` 9 ft. )0, ft i?U4 Nile d ,,)S'
Monitoring °Recovery ft. ft
Injection Well: '" V
ft. ft.
Aquifer Recharge DGroundwaterRemediation Aquifer Storage and Recovery Saul» Barrier 19.SAND/GRAVEL PACK(If applicable)
ry FROM TO MATERIAL EMPLACEMENT METHOD •
Aquifer Test °Stormwater Drainage ft ft
Experimental Technology IOSubsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheetsif necessary)
Geothermal(Heating/Cooling Return) ®IOther(explain under FROM TO DESCRIPTION(colon hardness.aoNrock type,grain,ize,etc.)
�} a#21 Rem(a,7rks) 0 ft. 6 ft }�,��, 'Cip��
4.Date Well(s)Completed:7.2 7 25Well ID# ..CI I' � l% 6, ft. Sc' ft s c NCCl •'?c c kid .
Sta.Well Location: 5-5- ft. (OS-ft• 'itre 6iz(tm A'e
aci6 /Owner Name ft ft ° "^^ II—e " ,
ty ,FacilitylD#(ifepplicable)
-,C-� -Ee,,r(v,S t�0 ft ft A U G 0 7 71123
Physical Address,
City,p and Zip ft. ft
/6.1APi! 2I.REMARIKS ill.;,'^ ":1;'... -:S.xv.:,..4 Ur:A
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W edt2 ,74.. , 7-,2 7- 2 3
6.Is(are)the well(s)'411'ermanent or °Temporary Signature of Certified We Contra or Date
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: DYes orID with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill outknown well construcfon 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 hackofthic 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 laud surface: (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths ifdifjerent(example-3©200'and 2(Qa 1005
construction to the following:
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10.Static water level below top of casing: (ft.) Division of Water Resources;Information Processing Unit,
fwater level Is above casing use"+" 1617 Mail Service Center,Raleigh,NC 276991619
11.Borehole diameter: 7-6 (In.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: / 02- ��1 i ii • above,also submit one copy of this form within 30 days of completion of well
0.e.auger,rotary,cable,direct push,etc.) constntctioa to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield••(gpm) 3 o Method of test: 5\1 i)-f- 2t4c.ForSupply Iniection Wells: In addition to sending the form to
the addressWater Sues) above, alsodt submit one co of this form within 30 days otf
13h.Disinfection type: Z"1TN Amount:f to 61 Z. completion of well construction to the countypy health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016