GW1--05878_Well Construction - GW1_20230918

i, i
i
li
WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only: 1 --___
I
1.Well Contractor Information:
Chris King ..It-WATER ZONES a j
Well Contractor Name FROMTO D CRIP,TION
2080-A )q oft. A/ ft O e T/C'
ft. ft. ! I
NC Well Contractor Certification Number
''15dOUTER°CASING(for multi-casedwells).ORLINER,(ifap licable)
Aqua Drill, Inc. FROM /TO' DIAMETERIAER i THICKNESS,y MAT RIIAAL `
Company Name e f t (P (�7 7f "n• ,f 5 &!T,
16.INNER CASI OR TUBING(geothermal'closcd-loop)
2.Well Construction Permit#: 4 ( e4/, 7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County,State.Variance,etc.) ft. ft. • in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
FROM - - •
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public ft. ft. in.,
Geothermal(Heating/Cooling Supply) ,,Residential Water Supply(single) ft. ft. in.
Industrial/Commercial • Ili'esidential Water Supply(shared)
18.GROUT
litigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. i) ft, p
Monitoring • j. ry ft. ft. �� Yt� �����S
Rccovc
Injection Well:
Aquifer Recharge ft. ft. ,
9 g Groundwater Remediation
Aquifer Storage and Recovery 49..SAND/GRAVEL PACK(if applicable)•-
g ry DSalinity Barrier FROM • TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology UI Subsidence Control ft. ft.
Geothermal(Closed Loop) tTracer 20:.DRILLING LOG(attach additionalsheetsif necessary) • . - -
Geothermal(Heating/Cooling Return) f Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock hype,grain stir.etc.)
4.Date Well(s)Completed: 4ell ID# ft. t. ALCel1l1 e/j? c/
Sa.Well Location: t2_5--ft. 1.25 ft. I
ue / r
i c
Facility/Owner Name Facility ID#(if applicable) ft. ft.
q i (tf4'r� r ciz� iZZ ft. ft. S E P [i�Z;
Physi al Address.City,and Zip ft. ft. I In r, hen PrC F ,
,jn_ + 21:REMARKS- �jyys y.-t,•}
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifica'
N W 7?-4:',
` �e��13
6.Is(are)the well(s -U''• manent or IDTemporary • Signature of Certified Well Date
Br signing this Rana,I hereby certify that the well(s)was(were)carstnteted in accordance
7.Is this a repair town existing well: DYes o f o with 1SA NCAC MC.0100 or 15A NCAC'02C.0200 Well Construction Standards and that a I
If iIiis is a repair,fill out known well corrstntetion a formation and etplain the nature of the copy of this record has been providal to the well owner.
repair under#21 remarks section or on the hack of this ftnm.
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-I is needed. Indicate TOTAL NUMBER of wells construction details. Youmay also attach additional pages if necessary.
drilled:
P � ft. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: v ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100'
1 construction to the following: i .
f)
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ijwnter level is above casing,use'+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
• 7 above,also submit one copy of this!form within 30 days of completion of well
12.Well construction method: .1 aff !�J 1 / construction to the following:(i.e. i auger,rotary,cable,direct push,etc.) g'
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield a ! I
(bPm) `j• Method of test: q h* 24c.For Water Supply&injection Wells: In addition to sending the form to
t the address(es) above, also submitloi a copy of this form within 30 days of
13b.Disinfection type: Amount:J� 2— completion of well construction to the county health department of the county
where constructed.
f
Fomi GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016