GW1--05602_Well Construction - GW1_20230825

WEILL
_,__ _=....CONSTRUCTION RECORD Il Print orm
For Internal Use Only: 1
1.Well Contractor Information:
Chris King
Con
W Y4.WATER ZONES
et! tracror Name I
FROM TO DESCRH'TiON
2080-A SW?' 35O ft 60 ' ,.
NC Well Contractor CertificationNumber ft ft.
Aqua Drill,Inc. Is.OUTER CASING far muffi.cased wells OR LINER .a,•ileable
FROM TO DIAMETER THICKNESS MATERIAL
Company Name El ftCl ft . in.
2.Well Construction Permit#: 7 2 7 7 c 2.3
16.INNER CASING OR TUBING thermal cle ed 1 r-n v
List all applicable well construction pelmets(i.e.UIC,County,State,Variance,ere) FROM It TO DIAMETER THICKNESS
in. MATERIAL
3.Well Use(check well use):
ft ft. in.
Water Supply Well: 17.SCREERT
I.A icultural Mtmicipal/Public FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
(Heating/CoolingI•Geothermal Supply) it ft in.
pP y) sidential Water Supply(single)
illIndustrial/Commercial OiResidential Water Supply sh ft ft in.*ilrri::tjon ppy( 10.GROUT
Non-Water Supply Well; FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
iiii Monitoring �� ft � ! f� 3�
Injection Well:- 1 Recovery
It.
*Aquifer Recharge DGroundwaterRemediation ft ft. ,
a!Aquifer Storage and Recovery °Salinity Barrier 19.SAND/GRAVEL PACK(ifapplicable) .
) a FROM TO MATERIALI EMPLACEMENT METHOD
�1AquiferTest OStormwaterDHaina
g it. ft
',Experimental Technology ®(Subsidence Control
R• ft
-Mt Geothemrai(Closed Loop) °Tracer '
20.DRILLING LOG(attach additional sheets if necessary)
a'Geothermal(Heatinp Cooling Return) *Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness.sall/racktype grain size,etc.)
o ft. �? ft. gCd
4.Date Well(s)Completed:3' — `7-2.�Well mu 3 ft. ft (!
Sn.well Location: ) 5 And JZQe K
rig- ft 3sT.) ft. aloe '&MAPa$e
ft. ft.
Facility/OtvnerName FaOih(yID#(if applicable) ft• ft
AV l 1
J�r.0 iJeZli R' ft' ¶ :.tb #-
Physical Address,City,and Zip�D ]"�—" ft, ft A I 1 Ci 21 5 L0/3
4/ l�lri rlr`tJ(" t,,. 21.REMARKS 1, J
e ln?4
County Parcel IdentificallonNo.(PIN) F I^D '''ra
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: brrratt a ...
n
(if well field,one!at/long is sufficient)
22.Certification:
N w 6e/A c• ,er.2
;. . - 7---2 3
6.Is(are)the wells) rmanent or Temporary Signature ofCenifi•Well Contract, Date
By signing this form I hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Iles or Eko with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Consnvclton Standards and that a
If this is a repair,fill out known well construction it formation and explain the nature of the copy o.fthis record d has been provided to the well owner,
repair under#2!remarks section or an 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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J ®
(ft.) 24a. for All Wells: Submit this form;within 30 days of completion of well
For multiple wells list all depths ifdperent(example-3(a 200'and 2@100)
construction to the following:
10.Static water level below top of casing: 3° (ft.) Division of Water Resources Information Processing Unit,
Ifwater level is above casing,etc'+' 1617 Mail Service Center,•Raleigh,NC 27699-1617
II.Borehole diameter: 6,
/� (In.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well constriction method: / I t�JZ9'// above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc,) construction to the following: j
FOR WATER SUPPLY WELLS ONLY: 1636
of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) !0 0 Method of test: 5i i 1'f�— 24e.For Water Supply&Injection Wells: In addition to sending the form to
` the address(es) above, also submit one copy of this form within 30 days of
13b.(Disinfection type: /'y—// Amount: () O't• completion of well,construction to the county health department of the county
where constructed. .
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016