GW1--05601_Well Construction - GW1_20230825

u
Print Farm
WELL CONSTRUCTION RECORD(GW4) For Internal Use Only.
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A a2ad it92,2I ft' ���174
ft. ft.
NC Well Contractor CenificationNumber 1S.OUTER CASING(for multi-cased wells)OR LINER Of ap :(cable)
Aqua Drill,Inc. - FROM TO DIAMETER THICKNESS MATERIAL
Company Name it. Si.
ft.
t 1/.7 in. !f `1 /.J
• 16.INNER CASINGT OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:5--2-- 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, tit. in.
Water Supply Well: 17,SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Ili Agricultural °Municipal/Public it It. in,
at Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. It in,
y'Industrial/Commercial 211 Residential Water Supply(shared) Is.GROUT
R iIrligation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ( r ft, t°g) ft_ /5r -held j¢e-. i',i i7 5.*Monitoring (°Recovery ft. ft I
Injection Well:
ft. ft.
iiAquifier Recharge °Groundwater Remediation
19.SAND/GRAVEL PACK Of applicable)
III Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
*:Aquifer Test °Stormwater Drainage ft, ft
Experimental Technology °Subsidence Control ft. ft.
*Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
11 Geothermal(Heatin_Coolin I Return) *Other Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardenssollfracktype grain sis etc.),
1 �/ Oft. S ft D v.j �I
4.Date Well(s)Completed:7a�/'/2. '2.5 Well lD# 16-T cX 6 Y it 55 qL 3'(i4,it(.1 /'o jc
Sa.Well Location: 5-9 ft. S ft' /JfGG 4fzi^itai 4- r-
t'�Rs,fr A o tut N S ft, ft.
Cies
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. ' F I'- E \ /�y
-S bC )4 AP Je5-I-tl�t L,j ft. f. a +r e.,..
Physical A
Address,City,and Zip ft, ft.
A U G 2 5`2023
A1.4trot 1✓c e- 21.REMARKS
County Parcel Identification No.(PIN) lIl(Fifi9.�L1di1 Prr..r. Una
LAN l.11:St1ly
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certif ica' n:
_
N W S - 12 - 2-3
6.Is(are)the well(s,tit' '- manent or Temporary Signature ofCertifie ell Contractor Data
By signing this form,I hereby cent&that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or rim, with 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a►epalr,f°/l out known well construction information and explain the nature of the copy of this record has been provided to the well owner
repair under#2I remarks section or on the back of this form.
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: .30, (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ft-different(example-3Q200'and 2Q100) construction to the following:
10.Static water level below top of casing: --7t2 (ft.) Division of Water Resources,information Processing Unit,
limiter level is above casing,use"+" 1619 Mail Service Center,Raleigh,NC 29699-1619
11.Borehole diameter: T' (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
f�Z �! ) above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: /Zt
construction to the following:
(i.e.auger,rotary,cable,d'mectpusb,etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1 1636 Mail Service Center;Raleigh,NC 29699-1636
T
5.I 13a.Yield(gpm) 5- Method of test: et h 24c.For Water Supply&Injection Wells: In addition to sending the form to
) JJ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type::/T/4 Amount:,(' 0 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