GW1--05919_Well Construction - GW1_20230918

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WELL CONSTRUCTION CORD GW-g Point Forts
For Internal Use Only:
I.Well Contractor Information:
Chris King
We
14.WATER ZONES I menConuactorName
FROM i0 DESCRIPTION
2080-A . 0 ft. 6 ft
NC Well Contractor Certification Number ft. ft.
'
Aqua Drill,Inc. 15.OUTER CASING formuid-cased wells OR LINER if a.,haiblo •
FROM TO DIAMETER THICKNESS
Company Name all ft , rt. /_ g! in. 501ZZ1 E�
2.Well Construction Permit#: ,2-0y 16•INNER CASING OR TUBBING :eothermal dosed-loo
List all applicable sell construction permts'(i.e.WC,County,State,Variance,etc.) FROM ft. TO ft DIAMETER
In.
3.Well Use(check well use): ft
ft. , in.
Water Supply Well: 17.SCREEtd.
U.Agricultural OMunicipal/Public FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
*Geothermal(Heating/Cooling Supply) ft. ft. In.
PP y) residential Water Supply(single)
}Industrial/Commercial jResidential Water Supply ft ft.
iJlrri_ation PPy(shared) IS.GROUT
Non-Water Supply Well: /FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
(Monitoring ft. /2© ft. Eeitf4iu i)C (- -5*Recovery �p
Injection Well: fL 1
SIlAquiferRecharge °IGroundwaterRemediation ft. ft
*Aquifbr Storage and Recovery jSalinityBarier 19 SAND/GRA•VELPACK(ifappllcable)
*Aquifer Pest �q, PROM TO MATERIAL EMPLACEMENT METHOD
p ilStormwaterDrainage ft. ft.
I Experimental Technology E3Subsidence Control
ft. ft 1 ,
*Geothermal(Closed Loop) °Tracer
20.DRILLING LOG(attach additional sheetsif necessa ' '• -
*'Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM To DESCRIPTION(color,harden,.sallfrock type,Rai•n sire,etc.)
a
rt. 6 ft p�c ' d J i Y
4.Date Well(s)Completed: 2-ii-2 3 mum ft.
/,t ft. I
sc1rud ' ILocK
Sa.Well Location:
1A ft 5—ft J3/(e• 6FZ►Aw -t
ft. ft.
Facility/Owner Name '
Facility ID#(if applicable) fL ft.
r-74� '1) N ft. ft. �n+vo r.,..t .�P.
Physical Address,City,and Zip ft. ft S E P 1 8 2023
Car4rulAr 21.REMARKS
County Parcel Identification No.(PIN) i II1l.7irl; .:7 f�!';=. ,N::�g °f.
Cr'd C:1:3• m1 5b.Latitude and longitude in degreesfminuteaseconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W ( 4�' 7 // —.y 3
6.Is(are)the wells) permanent or EITemporary Signature ofCertified1Ye11 Contrac Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ONo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifdtis is a repaint!!!out known well construction Information and explain the nature of the copy of this record d has been provided to the well owner.
repair under#21 remarks section or on the back ofthis form.
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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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
�� SUBM[dTTAL INSTRUCTIONS j•
9.Total well depth below land surface: O 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') construction to the following:
10.Static water level below top of easing: 3 d (ft.) Division of Water Resoarces,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: /r /g C/Z e I ) above,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 f
Division off Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY�W}ELLS ONLY: - ` 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) l v Method of test: S 1 Ot NA l
24c.For V e Wells: In addition to sending the form to
� �y the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:/f` - /J Amount: /ea d 7 completion of well construction to the county health department of the county
where constructed. j
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources ! Revised 2-22-2016