GW1--06292_Well Construction - GW1_20230926

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: 1 1
Chris King 14.WATER ZONES • p I
Well Contractor Name CIO ft FROM TO DESCRIPTION
2080-A `� / ft. '1 P t iNi
ft. ft. i
NC Well Contractor Certification Number
15.,OUTER CASING'(for multi-cased;Wells).OR LINER(itap livable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. c ft. 65/s in. IZt t I Pi li/ i L
_ ::16.INNER CASING OR TUBING,(geotbermal closed.00p)-
2.Well Construction Permit#.g,.l 12'' e2 02 5 -3r S )9.. FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C•County,State,Variance.etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN _ - ' _ ,
• FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public tL ft. in.
Geothermal(Heating/Cooling Supply) j2tiResidential Water Supply(single) ft. ft. in,
Industrial/Commercial QResidcntial Water Supply(shared) 18.GROUT
.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supp y Well: 0 ft.
0 ft. serti:hv►-k- 6...1Ytr;pS
Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge QGroundwater Remediation
19:SAND/GRAVEL,PACK(if applicable). '_- 1 ,
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLAC•EMENT METHOD
'Aquifer Test OIStormwater Drainage ft. ft. l'
Experimental Technology OSubsidence Control ft. ft. i
Geothermal(Closed Loop) OTracer ,20:DRILLING L•OG(attach additional sheets if.necessary)`•`•t -
Geothermal(Heating/Cooling Return) ['pother(explain under#21 Remarks) FROM TO DESCRIPTION.(color,hardness,soil/rock type.grain size,etc.)
Q � 0 ft. a ft. sz.eld c)K1
4.Date Well(s)Completed: ( `,:COI 3 Well ID# C ft. 5 C) ft- ))G l Z C:L i
•
5a.Well Location: so ft. 565 ft. GI I t, �C..r2 ¢4c
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. 1'c..r t,_,., „ , ,
.e �1 �j (i , "t v....e'4�R...s %, �-...L=
2 -tune,. t..Cxua N gA 7 odb�..JIA 91c j'V c ft. ft. (+rp ctt 0! (� Z
Physical Address,Q City,and Zip ft. ft. S L f .+ !r �v�`'
Ii � 1 )i 21.REMARKS' _ i' -i-_ ,. ';,—; pr:-rwia:.'.i•ur .'• . .
County Parcel Identification No.(PIN) ,• ~ DI C =BOG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W. / o- � 3
6.Is(are)the well(sPermanent or 1[ Temporary signature of Ccrtr red •wclf Contractor 1 Date
By signing this form,1 hereby certify[hat the well(s)was(here)constructed in accordance
7.Is this a repair to an existing well: FYes or i o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that tr
If this is a repair,full out known well construction infar•»tation and explain the nature of the copy of this record has been provided to die well owner.
repair under#21 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
S—� SUBMITTAL INSTRUCTIONS i
9.Total well depth below land surface:
(ft.) 24a. For All Wells: nmit this Iform within 30 days of completion of well multiplelriple wells list all depths ifd�ereut(example-3@200'and 2(41ao1
construction
truction to the following: I
10.Static water level below top of casing: ‘ 0 (ft.) Division of Water Resources,Information ProcessingUnit If water level is above casing,use"+" ,
1617 Mail Service Center,Raleigh,NC 27699-1617
Il.Borehole diameter: Cfa (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
o
I/(- 'Z- \` above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Ail._ 1 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: + 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 5 i Gt ei 24c.For Water Supply&Injection Wells: In addition to sending the form to
J�(T the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: d t 1 Amount: )/� 6 completion of well construction tot the county health department of the county
where constructed. I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 1 Rnvieod'-'9-'Snr C