GW1--05915_Well Construction - GW1_20230918

I_
WELL CONSTRUCTION RECORD GW For _ _
or Internal Use Only: _____
1.Well Contractor Information:
Chris King
WellI I
Contractor Name FROM
WATER ZONES ,l 1 -
FROM TO DESCRIPTION
2080-A j36 ft. )3 i ft. a o ! 6 i P!r't
NC Well Contractor Certification Number ft. ft.
Aqua Drill, Inc. 15.OUTER'CASING(for multi cased Wells)OR LINER(if ap licable).-
2.0 FROM {I TO[ DIAMETER CTHIICKNESSi MATERIAL
Company Company Name .3 0c G ft. I t,J'i ft. 16 yei, in. I J,P az 1 I 1 I t L
. ,,+- t�raF 16:INNER••CASI/NG OR TUBINGG (geothermal closed-loop)
2.Well Construction Permit#: ' _ids = 11 n1r FROM TO
List all applicable well constnction permits(i.e.UI .County.State,Variance,etc.) ft. DIAaETER THICKNESS MATERIAL
ft. in.
3.Well Use(check well use): ft. ft. in -
Water Supply Well: 17.SCREEN '.. ''
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) ceidcntial Water Supply(single)
ft. ft. in.
Industrial/Commercial
DRcsidcntial Water Supply(shared)
Irrigation 18,GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring ORecovcry �• ft. 6 ft. 9,,,,,4,,,,,..)e
�"�y'.�'� e t�i?S
ft.• ft.Injection Well:
Aquifer Recharge °Groundwater Remediation ft ft. ' .
Aquifer Storage and Recovery Salinity Barrier ,19.SAND/GRAVEL PACK(FROM TO MATEMATE icable)'
RIAL EMPLACEMENT METHOD
Aquifer TestStormwater Drainage ft. H.
Experimental Technology OSubsidence Control
ft. ft.
Geothermal(Closed Loop) OTracer
20:.DRILLING LOG(attach additionalshectaif necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DFSCRiPTION(color,kardness,soil/rock type,era;a size,etc.)
/S ft. 6 ft. zed , 6 I A )4.Date Well(s)Completed_9 .� Well ID# co ft. 39 ft. 1c
ci
5a.Well Location:
3 ��� i C C IC
ft. Sa-ft. r3 i�s�
, f2e5 A 12,E N I-0 ft. 1 �s,?►�t1ts�)�
ft.
Facility/Owner Name ' "-- •••" n'^•e t..•.r.•..•
Facility iD#(if applicable) D• ft. o-..
/ SO fl,i,Nf r_al)1 te. D a rVLC,Z ) P+®ivG 6jV ft. ft. .
•Physical Address.City,and Zip S P Q Q
�^ ft. ft. L
/ "-C). 6A ej 21.REMARKS.r•, s� r�::1 �r :>T ?. '
tr.: g:i.: ;t
County Parcel Identification No.(PIN) DA Cr`3C.V.3
5b..Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Celli cation:
N W ,
6.Is(are)the well(s)i%/lPermanent or QlTemporaryt�~ ��
Signature ofCcrtificd Well Contractor Date
/
•
this form.1 hereki,that the well(s
was(were)constructed in ccordance
gning
7.Is this a repair to an existing well: QYes or Aio witht15,4 NCAC 02C.0100 or 1SArNCAC 02CI.0200)Well Construction Standards and that a
If this is a repair,fill out known well construction it formation and explain the nature of the copy ofdus record has been provided to the well owner.
repair under#21 remarks section or on the hack of this•f rrm.
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 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
I -- SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: D (ft) 24a. For All Wells: Submit this form'',within 30 days of completion of well
For multiple wells list all depths ifdjerent(example-3L 200'and 2@100q
construction to the following: 1
10.Static water level below top of casing: Q
If water level is above casing,use"+" 3 (ft.) Division of Water Resources,Info/motion Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: a (in.) 24b.For Injection Wells: In addition to'sending the form to the address in 24a
12.Well construction method:
�~, d,�� above,also submit one copy of this formiwithin 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,
fi�ee,, 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) le' 1.
Method of test: ,9 n t 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: H T A Amount: 0'7.-. completion of well construction to the county health department of the county
where constructed. I
Fort GW-r North Carolina Department of Environmental Quality-Division of Water Resources
RrvicrA 7_99_9nt6