GW1--06211_Well Construction - GW1_20230925

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WELL CONSTRUCTION RECORD(GW-1)
For Internal Use Only:
1.Well Contractor Information:
Chris King
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14.WATER ZONES I I
Well Contractor NameFROM TO DESCRIPTION
2080-A 0130 ft' 23) n' '3 6-j Pti
NC Well Contractor Certification Number ft. ft.
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Aqua Drill, Inc. I5.OUTER CASIINjG(for muld.case�dy wells)OR LINER(if ap livable)
FROM© ft. I,C 1 H' I�}TO A5/Q In. I ,THICKNESScCI MATERIAL
Company Name1
`�R 16.INNER CASING OR TUBING(geothermal closed-loop).
2.Well Construction Permit#� ^CO I 33 FROM TO DiAMETER` THICKNESS MATERIAL
List all applicable well construction penni s(i.e.UIC.County.State,Variance,etc.) fL ft. , is
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER, SLOT SIZE .THICKNESS MATERIAL
OMunicipal/Public ft, ft. in.
Geothermal(Hcating/Cooling Supply)Residential Water Supply(single)
Industrial/Commercialft• ft. In.
ORcsidential Water Supply(shared)•
I IS..GROUT
Irrigation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: - ft. - ft. _
Monitoring ®Recovery i.Injection Well: ft. ft.
Aquifer Recharge @GroundwaterRemediation ft. ft.
Aquifer Storage and Recovery °Salinity Barrier 19-SAND/GRAVEL PACK Of applicable)
FROM TO MATERiAi: EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control
ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional Sheets if necessary)
Geothermal(Heating/Cooling Return) 3 Other(explain under#21 Remarks) FROM TO DESCRIPTIONDESCRIPTION(color.hardness.soil/rack type.grain sbc,etc.)
4.Date Well(s)Completed ft
�ir f t I�lve, I,a nw t-
WeIIID# ft. ft. i (�'
5a.Well Location: . _ ft. ft.
,3 .1 ft. ft.
Facility/OwnerNaine Facility ID#(if applicable) ft. it.
S'3z`(
CMG /Z -5� )14h1 hl.� ft. fr.
Physical Address,City.and Zips •t��._ m 1,
ft, ft.
GG ,l�ai-c� 21.REMARKS •
i-P �� .�! /�17.3 .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Iniorx, t✓n r�"`•""vxr.G: U6..
(if well field,one lat/long is sufficient) fltilfti# i 1>a
22.Certification:
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6.Is(are)the well(s ermanent or Temporary w signature a Certified Wellntr5etor -
i Date
Yes or ®No By signing this form,1 hereby cert f'that the lwell(s)was(were)meowed in accordance
7.I3 this a repair to an existing well:
If this is a repair.fill ma known well construction hiformation and explain the nature of the copy w �of this re•ord has been providedC 02C.0100 or NCACO2C.0200 lo the wn Well Construction Standards and drat a
repair under#21 remarks section or on the hack of this Arm.
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 i'
9.Total well depth below land surface: C 2�� (ft.)
For multiple wells list all depths((different(example-3(�200'and 2f!0O) 24a.For All Wells: Submit this form within 30 days of completion of well
26 construction to the following:
10.Static water level below top of casing: (ft.) i
If water level is above easing,use'•+ Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: U' (in.)
24b.For Injection Wells: In addition to(sending the form to the address in 24a
12.Well construction method: ,f CL 1 f above,also submit one copy of this form within 30 days of completion of well
(ie.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
13a.Yield(„•pm) 3 Method of test: S(.
1636 Mail Service Center,Raleigh,NC 27699-1636
��f'') 24c.For WaterSupply Br Infection Wells: In addition to sending the form to
13b.Disinfection type: ��� •-� the address(es) above, also submit one copy of this form within 30 days of
Amount completion of well construction to the county health department of the county
where constructed.
Fomi GW-1