GW1--04989_Well Construction - GW1_20230807

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WELL CONSTRUCTION RECORD(GW41 For Internal Use Only. I
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM To DESCRIPTION
2080 A 3,70 ft. , 71 ft 5-0lT I p1 rvi
ft ft.
NC Well Contractor Certification Number _
15.OUTER CASING(for multi-cased wells)OR LINER(flap lIrable)
Aqua Drill,Inc. FROM TO DIAMETER THICKNESS g MATERIAL
Company Name t ft 0�Q. /`u 6 in. SDIZ)1 I
(� 1 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: Cl 1 1 l C{ 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 '
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) 4Stsesidential Water Supply(single) R, ft, in.
Industrial/Commercial °Residential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft qq ft
eD oC G 9e)04N'liked-IN, S
Monitoring DRecovery ft. ft
Injection Well:
Aquifer Recharge ft. it
q g Groundwater Remediation
Aquifer Storage and Recovery p�Salim Barrier 19.SAND/GRAVEL PACK(if applicable)
LI' tY FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IDStormwater Drainage ft. ft
Experimental Technology (°Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under 421 Remarks) FROM TO DESCRIPTION(color,hardness.soi Jrocktype groin vise etc.)
�721-6
CI
0 fr. ft Rea Clay
4.Date Well Os)Completed: / -27 KW#k O'� 13 6 ft• IU o ft n oci Ro G }'v1.0 d
!
Sa.Well Location: 10C� f' lt�,Crt Ij IU�- (�-�,f l�e
ft. ft. ! 1
Facility/Owner Name Facility ID#(if applicable) ft. ft ,,`"
Y\Nn)� /; P-Twx PA ft ft. F. s e V �'qti
Physical Address,City,and Zip ft ft Q i I r c) ')n'
go .,j 4.311El.REMARKS :1
County Parcel Identification No.(PIN) Ifl vi7:1.54:.'Cf) sPr.^-^:,. ,,, err_
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: D'~°! ut�+y
(if well field,one latllong is sufficient) 22.Certif cation:
N W ( � 13/� � _
6.Is(are)the wells ermanent or °Temporary Signature ofCet red Well Cmrttdctart to
By signing this font,I hereby certify that the well(s)was(here)constructed in accordance
7.Is this a repair to an existing well: *Yes or io with ISA NCAC 02C.0100 or ISA MAC 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 provideed 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-)is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
2 75` SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdlPrent(example-3Q200'and 2f1005 construction to the following:
10.Static water level below top of casing: 3 6 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"l+' 1617 Mai Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ' A (in.) ;7 246.For lniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: / t) t� , above,also submit one copy of this form within 30 days of completion of well
construction to the followin
(i.e.auger,rotary,cable,direct push,etc.) g
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
�^ 1636 Mail Service Center,Raleigh,NC 27699-1636
J 13a.Yield(gpm) O Method of test:St Cy,i"t 24c.For Water Supply 8s IInieclion Wells: In addition to sending the form to
7� J -7 the address(es) above, also submit one;copy of this form within 30 days of
13b.Disinfection type: 1 Amount: 6 0 [- completion of well construction to the county health department of the county
where constructed. I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2..22-2016