GW1--05879_Well Construction - GW1_20230918

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I I
1.Well Contractor Information:
Chris King .14:WATERZONES i' •'
Well Contractor Name FROM TO D CRIPT�IO'N,�
2080-A )q Oft. ! q / ft, 0(J�,F�/�
ft. ff ft.
NC Well Contractor Certification Number
IS,OUTER.CASiNG(for multi-cased wells)OR LINER'(if ap iicable) .
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MAT RIAL
Company Name 19 ft � /•fl"1n. ,/ • d ic/
A 16.INNER,CASING OR TUBING(geothermal closed loop) LLL���Y?
2,Well Construction Permit#: J� e,Z,..52 7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,Coentp,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
Agricultural f Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) jj Residential Water Supply(single) ft. ft. in.
Industrial/Commercial III 'csidential Water Supply(shared)
18.GROUT
i Irrigation FROM MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ° ft, TO t✓�, ft. / p
-12fX1 Te Cher S
Monitoring
QRccovcry ft. ft.
Injection Well:
Aquifer Recharge ft. ft.
q g Groundwater Remediation
Aquifer Storageand Recovery .19.'SAND/GRAVEL PACK(if applicable),
q jSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology LISubsidence Control ft. ft. ,
Geothermal(Closed Loop) jTracer _20.DRILLING LOG:(attach additional sheets if necessary),.` '
YOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size.etc.)
Geothermal(Heating/Cooling Return) L
r 0 ft.
6 it. 'tti c
4.Date Well(s)Completed: �A8" - ell ID# Cl_ ft. 1ri ft. C��GGt -
Sa.Well Location: _2.$' t. 25 it t2 I ue 4/2,r/tit 4
ft. ft.
Facility/Owner Name Facility1D#(if applicable) ft. ft. Fi.'i,";t': -, et1E.•� t
qi 6/- fit. �-t1/-� /n`c,f ft. ft. -Y ..-..,7 ...°
Physi al Address,
City,and Zip ft. ft: S k f 1 C UZ�
!/f�/`� t t� 21,'REMARKS ' ' _
1rn0„,,:.:.;;-or 1-c.-^1.,544:•P.g lira
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.Cel'tifica
N W / ' ‘ 5s1-2Y-.2.3
6.Is(are)the well(SARet-manent or Di Temporary
Signature of Certified ell antractor Date
By signing thisAnn,I hereby certij•that the well(s)was(Were)consutrcted in accordance
7.Is this a repair to an existing well: :Yes o ndo with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well couctruclion ipforutatton and etp�ain the nature elf the copy of I/is record has been provided to the well orvuer.
repair tinder#21 remarks section or on the hack ofthis•flow:.
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
constriction,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: (ft-) 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@I001
construction to the following:
10.Static water level below top of casing: t� (ft.) Division of Water Resources,information Processing Unit,
If water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 246.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: -� ! above,also submit one copy of this form within 30 days of completion of well
Ae r /—,7 I construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program, '
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)10 Method of test:Dq iii•Ar 24c.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: J Amount:f �— completion of well construction to the county health department of the county
where constructed. I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016