GW1--05593_Well Construction - GW1_20230825

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only.
I.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080 A es2M e202/ 't• 5 ie,174 .
H. ft. II
NC Well Contractor CertificationNumber IS.OUTER CASING(for mutE-cased wells)OR LINER(ifap limbic)Aqua Drill,Inc. FROM TO DIAMETER I THICKNESS MATERIAL�
Company Name . 0 ft. / ft. ‘r7 in. ti S
• n 16.INNER CASING OR TUBING(geothermal clased.loop)
2.Well Construction Permit#:5-2-2-_�.3 C✓le.� ,�( FROM TO DIAMETER r THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. ft. In.
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3.Well Use(check well use): ft. ft. it
Water Supply Well: 17.SCREEN
ttgq,A*riCUitnral FROM TO DIAMETER SLOT SIZE THICKNESS . MATERIAL
Q b . ;a Mttnicipal/Public ft ft. in. i
DGeothermal(Heating/Cooling Supply) residential Water Supply(single) R. ft in.
Dlndustrial/Commercial it!Residential Water Supply(shared) la GROUT
('Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply ft
PPY Well: ft. �� /304110I¢e. d 4 ipS
DMonitoring it Recovery g. ft.
Injection Well: rt. ft.
Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK(If applicable)1
®(Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
EDAquifer-Test ®IStormwaterDrainage ft. ft. i.
DExperimental Technology DSubsidence Control R. ft.
DGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary) '
Geothermal(Heating/Cooling Retain) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,turdoocvs,solllroclttype,grain e�etc.)
f.
4.Date Well(s)Completed:7a'/1 '25 We11ID# IO+ oe to tY ft 5-5 5 4,y d ���4 c}7 C C`
So.Well Location: j 9 ft 29.- ft /3ff,e. Tlr2y'Tput I c- .
` 2i4r,t e faotk I 1Nc •
ft. ft. _
Facility/Owner Name Facility ID#(if applicable) n' R. E C E i/E
S009 /4 lip afes'I-r!t`c[L) ft. ft. AUG 2, �'202�
Q
Physical Address,City,and Zip
`iSoor`✓Le- 21.REMARKS 9
tflfNlftraiso.:rii i- ..:vv.,, 5,:. --r
County Parcel Identification No.(PIN) 1 (11,At0/10G '
5b.Latitude and longitude in degreeslminutes/seconds or decimal degrees: i
(if well field,one lat/long is sufficient) 22.Certitica• n:
N W t .,' 1. S. - 12 - 2-3
6.Is(are)the well(sPermanent or Temporary Signature of Certifie ell Contractor Dace
T��// By signing this form,I hereby cert'that the;ivel(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or ErNo with 15A NCAC 02C.0100 or ISA NCAC 02C•.0200 Well Constntation Standards and(hat a
!Phis is a repair,Jul out known well construction information and explain the nature of the copy of this record has been provided to the well owner:
repair under 021 remarks section or on the back gilds form. 1'
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 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1.
SUBMITTAL INSTRUCTIONS i
9.Total well depth below land surface: >?�,• (ft.) 24a.For All Wells: Submit this farm within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100' construction to the following: i
10.Static water level below top of casing: IC? (ft.) Division of Water Resources,IInformation Processing Unit,
'twofer level is above casing.use„+•' 1617 Mail Service Center;Raleigh,NC 27699-1617
11.Borehole diameter: " (in.) 1 '
) 246.For Injection Wells: In addition to sending the form to the address in 24a
Z G�lZi ) •
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: A(i.e.auger,rotary,cable,direct push,etc.) ! construction to the following: i
Division of Water Resources,Undergrrtinnd Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,lRaleigb,NC 27699-1636
13a.Yield(gpm) 5- Method of test: I h'- 24c.For Water Supply&Injection W ills
`� : In addition to sending the form to
f the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:.,!r/1 Amounl:)(JJ e,e- completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ! Revised 2-22-2016