GW1--06564_Well Construction - GW1_20231006 (2)

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES I ; -
Well Contractor Name FROM TO DESCRIPTION
2080-A 377 ft. 37/ n. S r i p,(y-
�565 ft. 6 6 ft. S- 1 i',ri
NC Well Contractor Certification Number
15.OUTER CASING(for multi-casedlwells)OR LINER(flap licable)
Aqua Drill, Inc. FROM TO DIAMETER I THICKNESS MATERIAL
• ft. ft. in.
Company Name
/° 16.INNER CASING OR TUBING(geothermal closed-loop) - -
2.Well Construction Permit#: (� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pe rs(i.e.U1C County,State,Variance,etc.) /�} ft. 5 ft. / r�q in. cola .( Pi i' r/s
3.Well Use(check well use): [t �, ft. ft. cC9 in. �
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural M
0unici al/Public
L.:1 P ft. ft. in.
Geothermal(Heating/Cooling Supply) csidential Water Supply(single)
ft. ft. in.•
'Industrial/Commercial DRcsidential Water Supply(shared)
18.,GROUT .
ITigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. /n ft. / ,1i ,l_e y (p S
Monitoring DRccovcry ft. �L l ft. I!
Injection Well:
ft. ft.
Aquifer Recharge
Groundwater Remediation
Aquifer Storage and Recover 19.SAND/GRAVEL PACK(if.applicable)'__ -
y 0 Salinity Barrier FROM TO MATERAAI. EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology (Subsidence Control ft. ft.
•
Geothermal(Closed Loop) OTracer 20 DRILLING LOG(attach additional sheets if necessarv) r= _
Other(explain under#21 Remarks) FR°af TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return)
////
O ft. so- ft. /zed' e [ 0 /
4.Date Well(s)Completed:(-2 7'2 3 Well ID# , .- ft. C/O ft. SVl tti . Roc K
�j /� 5a.Well Location: qo, ft. S OS-ft 13it�e f7Z)?1L)i-I e
`� / tidy gic �^ce t the. Dept ft. ft.
Facility/Owner Name Facility iD#(if applicable) ft. ft.
6q (dam, •� (,,� G.�q 7 yp , -m n f"'r't,
V"65 N to c - ✓L 1 •J•1'_In\ ��• 14q 1. N .C f ft. •_"m....r;,N-^.r-r; k..,,.,4.
Physical Address,City,and Zip ft. ft. OCT 0 6 2n2,
S-1-Q( . c 21.REMARKS • - ' I'
County Parcel Identification No.(PIN) Ink F1 a . .. 3 I,..;
C'•',ter: C.•1.13
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat./long is sufficient) 22.Certification' s
'%%ro
St orate o 1 -'.7-'4 3
6.Is(are)the well(s Permanent or IQTemporary f Certific Well Contractor Date
By signing ibis jiwin,I hereby cert fi thatthe well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dies orr, o with iSA 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 COp)'0-this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis•form.
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 details. You may also attach additional pages if necessary.
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:
SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: ‘0. (ft-) 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: 1
10.Static water level below top of casing: 6 0 (ft.) Division of Water Resour ies,Information Processing Unit,
If water level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: I(in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: f7/�� Cl�j ' 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
�ry
e 1
13a.Yield(gpm) 0 Method of test: .&c11 24c.For Water Supply&IniectionJWells: In addition to sending the form to
the address(es) above, also submit tine copy of this form within 30 days of
13b.Disinfection type: HIP Amount: 16 0 .. completion of well construction to the bounty health department of the county
where constructed.
•Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-7.01 fi