GW1--05595_Well Construction - GW1_20230825

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WELL CONSTRUCTION RECORD(GW4 For Internal Use Only Print Form
1.Well Contractor Information: I
Chris King 14.WATER ZONES
Well Connector Name FROM TO DESCRIPTION
2080-A 155'`t• 15`6: ft 20 K i pt Pn
ft ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multicased wells)OR LINER(if no tkable)
Aqua Drill,Inc. FROM TO DIAMETER, THICKNESS MATERIAL
Company Name G ft. 63 it 7g in. ,,i�1 s 61:4el/
c f ,p f j� 3 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#• s /7I JCL FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.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
I •Agricultural �•Municipal/Public ft. ft. In.
If Geothermal(Heating/Cooling Supply) a gesidential Water Supply(single) ft ft. In.
y'Industrial/Commercial DResidential Water Supply(shared)
!Irrigation 18.GROUT
FROM TO MATERIAL ' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. .26 It 3eyt)-levI!-e rt 7 ;p f
A:Monitoring ,*Recovery ft. ft r�Gr J
injection Well:
ft.
ill Aquifer Recharge ID' GroundwaterRemediation ft.
Aquifer Storage and Recovery Salmi Barrier 19.SAND/GRAVEL PACK(if applicable)
tY FROM TO MATERIAL EMPLACEMENT METHOD
*Aquifer Test DIStormwater Drainage ft. ft.
*Experimental Technology I" Subsidence Control ft. ft.
ft Geothermal(Closed Loop) IOTracer 20.DRILLING LOG(attach additional sheets if necessary)
a Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness eolllroektses grain gin etc.)
V Z 0 ft ✓? n. RC/ ' C/n / _
4.Date Well(s)Completed: .)Well ID# 3 fh 75- ft 5 4-N S, Rd C
Sa.Well Location: 5-5- ft' j/c s"-ft g'i 1 e Z7zi'tl i 4-c-
tt. ft.
Facility/Owner Name Facility ID#(if applicable) R. ft
Rom' o a',r:.'p1 i m'
i 1.5 Pc,,(e t)-1 e..orociC piz ft. ft. 1 N. %,..o L.e VI..L.,/
Physical Address,City,and Zip ft. ft. Mir] 6? 5 21171
�/ MAfrii t e L j-do is- 21.REMARKS
County Parcel Identification No.(PIN) ist$r%41714r4dil Psncoaufzg(.lick
OftISOCe
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees: aQ
(if well field,one tat/long is sufficient) 22.Certifica// 'on:
N W i' IS .cp --_.26.Is(are)the well(s rmanent or Temporary Signature of Certified ell Contractor Date
By signing this form,I hereby certify that the'wells)was(were)constructed in accordance
7.Is this a repair to an existing well: pies orVo 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 ofthis record lies been provided to the well owner
repair under#21 remarks section orm:the back of thisfonn.
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: I VJ (ft) 24a.for All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths((different(example-3@200'and 2@100�
® constructionng:to the followi 1
10.Static water level below top of casing: (ft.) Division of Water Resources,Information ProcessingUnit,
If water level Is above casing,use"+'
1617 Mall Service Center,'Raleigh,NC 29699-1619
11.Borehole diameter: 6 (in.) 24h.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: hi)17 �1Z4,,I above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) const[uction to the following i
FOR WATER SUPPLY WELLS ONLY: - Division of Water Resources,Underground Injection Control Program,
1636 Marl Service Center,Raleigh,NC 27699-1636
13R.Yield(gpm) 2® Method of test: 5 g 1'1+ 24c.For Water Supply Fc!infection Wells: In addition to sending the form to
d (� J/� the address(es) above, also submit one copy of this form within 30 days of
1311.Disinfection type: f 1 E 1 Amount: O's. 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 Resource Revised 2-22-2016