GW1--06064_Well Construction - GW1_20230921 (2)

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WELL CONSTRUCTION RECORD (GW-1) I For Internal Use Only:I.Well Well Contractor Information: 1
Chris King
14.WATER ZONES i j ,
Well Contractor Name FROM TO DESCRIPTION
2080-A 3 7oft. 7) ft. 5 if 1''1 po 1,
NC Well Contractor Certification Number ft. ft. I
Aqua Drill, Inc. 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable) , -
FROM I TO DIAMETER" THICKNESS MATERIAAL -
Company Name 0 ft. 6C� ft. I/' /IC/ in. �La1-z 2,1 pit),c
5��f[' -20 2 16.,INNER CASING OR TUBING�S (geothermal)closed-loop)' 11
2.Well Construction Permit# 3 5 �' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State.Variance.etc.) ft. ft. in.
•
3.Well Use(check well use): ft. ft. in.
Water Supply Well: I7.SCREEN
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Municipal/Public ft. it. in.
Geothermal(Heating/Cooling Supply) eFR,csidcntial Water Supply(single)
Industrial/Conuncrcial ft• ft. in.
�IResidential Water Supply(shared)
Irrigation 18.GROUT- •
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring [t. r')s,� ft �C,��#�i ie Gy i ��
QRecovery ft. f 1 ft. '1
Injection Well:
Aquifer Recharge °Groundwater Remediation ft ft.
Aquifer Storage and Recovery Salinity Barrier .19.SAND/GRAVEL PACK(if applicable)'• __
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stoumwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer
20.DRILLING LOG(attach additional sheets if necessary) •
Geothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain si e,etc.)
O ft. / ft. Ze d e q A ,'
4.Date Well(s)Completed:9 -/( "23 Well ID# 6n ft. ft. 5�rya [R c c IC
5a.Well Location: ss- ft. `)2 tl/`Lie `�r a m)u C
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Ho hog iZ;( f� biz 5{r ,fir 11n ii'P 1tv,t ft. ft. it—,%..?ii.. , ie r11.
a�'.
Physical Address,City,and Zip ft. ft. n
y
1Z.r,d C ) 1 21.REMARKS. T P . -
County Parcel Identification No.(PIN) �r;^. r 1P'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: v! ''' t'
(if well field,one lat/long is sufficient)
22.Certification:
N W _
6.Is(are)the well(sFermanent or Temporary SignatZIcd Con star I _ 23
Date
By signing this form,I hereby certij'that the we/l(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes orfo with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature oldie copy of this record has been provided to the s/e11 owner.
repair under 421 remarks section or on the hack of this form.
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:
(� SUBMITTAL INSTRUCTIONS •
9.Total well depth below land surface: �J (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths Idi(ferent(example-3 rr 200•and 2@I00')
construction to the following: I
10.Static water level below top of casing: Q l
If water level is above casing.use"+' (ft) Division of Water Resources,iInformation Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.)
24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: A-? !�/. ci. {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:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,'Raleigh,NC 27699-1636
13a.Yield(gpm) J
13b.Disinfection type: % �� Method of test:5 1 CI Yl f 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
Amount:/// 6 7.. completion of well construction to the county health department of the county
where constructed. I
Form GW-I North Carolina Department of Envimnmentnl Onalit,,-n:,a,.;,.«..oni..._-n...---.