GW1--05600_Well Construction - GW1_20230825

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I I Print Forrn WELL CONSTRUCTION RECORD(GW4 y. !' For Internal Use Onl .._.:_._._._....._`_._ .
I.Well Contractor Information: I
Chris King I4.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080.A 7J ft 7z ft. 15` j,217e 1,6,.1 .
NC Well Contractor Certification Number ft. ft
Aqua Drill,Inc. IS.OUTER CASING(for multicasedwells)OR LINER(rfep limbic)
FROM TO DIAMETER THICKNESS MATERIAL j
Company Name © IL 1 J/ rt. 1('5/e in. I 1,�?8 A 14lt
2.Well Construction Permit#: . l j? N) 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pennits(i.e.UIC,Couuy,State,Variance,etc.) N. it. ,to.
3.Well Use(check well use): ft. ft. in
Water Supply Well: 17.SCREEN
Agticuitural FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
°Municipal/Public - ft. ft. in. ;
Geothermal(Heating/Cooling Supply) ''t esidential Water Supply(single)
ft. ft. in. '
Industrial/Commercial
Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT M &AMOUNT
Non-Water Supply Well: �p �i
ETHOD
Monitoring Recovery �-> ft ft. er iillt, i'1 t
Injection Well: - R'
Aquifer Recharge DIGroundwater Remediation R. f t
uifer Storage and RecoverySalinity Barrier 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DIStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness sni0mrk type groin sue etc.)
Q° / 0 ft. 3 ft. ea !
4.Date Well(s)Completed:J "l4 7 We y A).1- OJ t3J ft 10 ft ,f 1 gAr g_
55aa..Well Location: /0 ft IC(s-ft 13 R�e't /-izelh 1e
ft. ft.
Facility/Owner Name FacilitylD (ifapplicable) .� _.._ t
# C.
SO 97 /41.1v1/c5 - i et-3 1)R ft. AUG20"c3
Physical Address,City,and Zip
4h9tvney11-7P, 21.REMARKS
9
County n n ttr,t r..:rs..:r.g t,a..
Parcel Identificat➢on No.(PIN) r)Wll/a^iMOrs
5b.Latitude and longitude in degreesfminutesfseconds or decimal degrees:
(if well field,one ltlong is sufficient) 22.CattIfi ation:
N W '- 1. ,
6.Is(are)the wells) ermanent or Te ary �� `�'�
mpor is-nature otor 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: °Yes orit& with ISA NCAC 02C.0I00 or 1SANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out lotown well construction Information and espiabt the nature of the copyoflhis record has been provided to the well owner:
repair under#21 remarks section or on the back aphis fort.
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 GWN 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: L2)S, (ft.) 24a.For All Wells; Submit this farm within 30 For multiple wells list all depthsifdyerent(exanple-300'atd2@Ioo) days of completion of well
ii construction to the following: ,
10.Static water level below top of casing. I 0 (ft.)
Ifwater level is above casing,use"+" Division of Water Resources,Information Processing Unit,
1619 Main Service Center Raleigh,NC 29699-1619
1H.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method:�/�� �,]) ) above,also submit one copy of this forest within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,(Underground Injection Control Program,
1636 Mail Service Center,'Raleigh,NC 29699-1636
13a.Yield(gpm) I Method diva: .tf- k.- 24c.For Water Supply&Injection Wells; In addition to sending the form to
��1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Oa 14 Amount: 17. 6 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