GW1--05918_Well Construction - GW1_20230918

WELL CONSTRUCTION RECORD(GW-1)
! I
I For Internal Use Only:
1.Well Contractor Information: I
Chris King ,
14.WATER ZONES _ i';
Well Contractor NameFROM TO DESCRIPTION
2080-A 3 60 ft, 3c/ fL 9 gl,i'.jvt
NC Well Contractor Certification Number ft ft.
Aqua Drill, Inc. 15.OUTER CASING(for multi-cased wells)•OR LINER(if ap licable).: _. __
FROM I TO DIAMETER THICKNESSES MATERIAL
Company Name V ft. I C�4' ft.i/�� in, sD!z.2I �✓.
02 3 C. j/ 16.INNER IIICASING OR TUBING(ceothermal.closed-loop)'._.
2-Well Construction Permit#: /J1 C. !(G FROM TO DIAMETER THICKNESS MATERIAL
List all applicable tie!!construction permits(I.e.U1C,County.State,Variance,etc.) ft• ft. in.
3.Well Use(check well use): tL ft. in,
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL'
QMunicipal/Public ft. ft. in,;
Geothermal(Heating/Cooling Supply) ESIZ,esidential Water Supply(single)
ft. • ft. in.
Industrial/Commercial
DResidential Water Supply(shared)
Irrigation 18,GROUT ,
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6ft. �`j� ft. 1
Monitoring DRecovcry 'tee � 1t�' ��f<
ft. ft.
Injection Well:
Aquifer Recharge 0Groundwater Remediation ft ft.
Aquifer Storage and Recovery Salinity Barrier 19.SAND/GRAVEL;PACK(if applicable) , .
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStonnwater Drainage ft. ft. 1
Experimental Technology QSubsidence Control ft. ft. 1
Geothermal(Closed Loop) IDTracer 20:DRILLINGLOG;(attach additional`sbeets if necessary)
Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) FROM To DFSCRIPTION(color,hardness,soil/rack type,grain size,etc.) -
iP 1 ft, / ft. ila-, .-'j . (Op y
4.Date Well(s)Completed 1 ' 23 Well ID# C/ ft. (�fj� ft.
5a.Well Location: (C1 ft.
t gift, �� ��fG,e
4.f� � s..� Cl() . �AD3` �► e6z�K:lae
ft. ft.
Facility/Owner Name Facility lD#(if applicable) ft. ft. r
i/' f et2t3l+.a ►'3 ► N La it ory 5- 6VC
Physical ft. ft: �.r ,d t... + a 9�.
E fp g L013
1110 N ).1%1 UL/
IWO:vtw.
.21:REMARKS'
Address,City,and Zip ft. ft.
County {{ Parcel Idcn6ficationNo.(PIN) ,".tl PI'•""SI"s'^" fir
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certification:
,,,� N W
a.,'2 .1 )9)-r._.6.Is(are)the well(s)#Yl1tP rmanent or Temporary Signature of CertifiedWell Contractor vO
J�'� D tc
7.Is this a repair to an existing well: jYes or ,)2'►o twitht SA NCAC 02C.0100 herebygning this Arm,I ISArNCAC 0�that rC.0?00e )Well C was(were)
rstruction Standouts and that a
If this is a repair,fill out known well construction information and explain the nature tithe copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis foun.
23.Site diagram or additional well details:
3.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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
/y
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1'a S (ft-) 24a. For All Wells: Submit this fomi within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@1001
/� construction to the following:
10.Static water level below top of casing: V (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: (in.)
24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: ��. re-isabove,also submit one copy of this form within 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,
a e.—
13a.Yield(gpm)
Mail Service Center,Raleigh,NC 27699-1636
bP ) Method of test: 'kill 24c.For Water Supply&Infection Wells: In addition to sending the form to
1the address(es) above, also submit one Icopy of this form within 30 days of
13b.Disinfection type: /)7 4 Amount:16 e completion of well construction to the county health department of the county
where constructed.
D...4.....3.1.1,, ..
Fort OW-I North Carolina Department of Environmental Quality-Division of Water Resources