GW1--06565_Well Construction - GW1_20231006

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I------
1.Well Contractor Information:
Chris King 14.WATER ZONES I
Well Contractor Name FROMTO DE CRIPTION
2080-A 7O ft. ,7) ft. . 6 e 1 l'''1
ft. It.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(iiapEiicable)
Aqua Drill, Inc. FROM TO DIAMETERI THICKNESS I MATERIAL
Company Name 0 ft I S 0 ft I .iy lin!I G o/Z 2( Ir
Fit/Fit/'7 16.INNER,CASiNG.ORTUBING(geotliermal closed-loop)
2.Well Construction Permit#: / 9FROM 'TO DIAMETER'. THICKNESS MATERIAL
p
List all applicable well construction',,Mils 0.e.OIC,Camp•,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
all Agricultural DMunicipal/Public ft. .ft. in.
Il'Geothermal(Heating/Cooling Supply) £Residential Water Supply(single) ft ft. in.
®i Industrial/Commercial DResidcntial Water Supply(shared)
18.GROUT,
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
t^� ft. ,26 ft. •
i ✓t9�aUa�C GhT�
"Monitoring �Rccovery ft. ft.
�� t —
Monitorini7 C f
injection Well:
-
INAquifer Recharge 0Groundwater Remediation ft. ft.
"Aquifer Storage and Recovery 19.SAND/GRAVEL PACK(if applicable) . .
IQISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
IIII Aquifer Test Et Stormwater Drainage ft. ft.
al Experimental Technology oSubsidence Control ft. ft.
Geothermal(Closed Loop) ;—Tracer =20.'DRILLING_LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ii Other(explain under#21 Remarks) FROM TO DESCRIPTION(colpor,rharddness soil/rock type,grain size,etc.)
t :CUP,~i 3 /0 ft. ft. (Led. • t 1 A
4.Date Well(s)Complete . Well ID# c� fit. C j 5— fit. Si id iZo C(C
5a.Well Location: ft. ft. 1
u S ?� 131ur 4Pz1+aIvl:le
ei l4-6IU ft. ft.
Fad ity/Owner Name Facility iD#(if applicable)' ft. ft. _
an 54-6-c)c i? . `.. t.:. `L,,
f J Pic t s=C ft. ft. ( ,
Physical Address,City,and Zip ft. ft. U C T 0 V 2023
5+Ore 5- 121:REMARKS' • -
County (PIN)
Intow,�:fk..a Pr.:-:.:5,:,!:;.-a lief
Parcel Identification No. G h ;,'`. l�l:.t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: d v�
(if well field,one latllong is sufficient) 22.Certification:
N
W ,
6.Is(are)the well(s)rbermanent orDiTemporary rgnaturc of Certified ell Contract Date
-�� ,
By signing this flirts,1 hereby certify that the tt•ell(%)was(were)constructed in accordance
7.Is this a repair to an existing well: f Yes or i2ko with 15A A'CAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repak fill out known well conmmtatlon information and explain the nature(dale copy of this record has been provided to the well(Aruer.
repair under#21 remarks section or on the hack of this 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,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: 3Q, (fit.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii different(example-3@200'and 2@I00')
/g construction to the following:
10.Static water level below top of casing: Cr� (ft.) Division of Water Resources,es Information Processing Unit,/!t+'(ter level is above casing,use//+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: frF (in.)
24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this!form within 30 days of completion of well
12.Well construction method: 4/R Uzi j i construction to the following: I ,
(i.e.auger,rotary,cable,direct push,etc.)
I
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service'Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: S i�61 I' 24c.For Water Supply&Injectio�Wells: In addition to sending the form to
the address(es) above, also submit'one copy of this form within 30 days of
i
13b.Disinfection type: `V -A Amount:)2 o Z— completion of well construction to the county health department of the county
where constructed. 1
Fort GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ; Revised 2-22-2016