GW1--06570_Well Construction - GW1_20231006

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�C
2080-A 196 ft. 'QK/ ft' J 6. i i't i-A
ft. ft.
NC Well Contractor Certification Number
15,OUTER CASING(for multi-eased wells)OR LINER(if au'lieable)
Aqua Drill, Inc. FROM TO DIAMETER , THICKNESS MATERIAL
P Y n C •ft. 30 ft. 6 (/ a in, 1 o RZ) p 11r l c
Corn an Name ✓ t!
`7 16.iNNER.CASiNG.ORTUBING(geotbermal•closed-loop),
2.Well Construction Permit#: r FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constnfction permits(i.e.UIC County.State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft, ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0 Agricultural 0 Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) csidcntial Water Supply(single) ft, ft. in.
Industrial/Commercial I0Residential Water Supply(shared) 18.GROUT ;
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD Sc AMOUNT
Non-Water Supply Well: r ft. �6 ft. dcm ) C. C III
Monitoring 0Recovery ft. ft.
Injection Well: ,
ft. ft. '
Aquifer Recharge Groundwater Remediation
19s`SAND/GRAVEL PACK(if applicable): -. ' - - '-
DAquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. ft. 1
0Experimental Technology (Subsidence Control ft. ft.
Ej Geothermal(Closed Loop) DITracer 20;+DRILLING'•LOG(attach:additional;sheets if necessary)`. ' .`
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal•(Heating/Cooling Return) nOther(explain under#21 Remarks) �� ft. ft. Ke. (I ;� j ./
4.Date.tWell(S)Completed o2.5 -a2.3 Well ID# `! te/ / v
ft. y ft. „1 UxI l�L"t G/� _
5a.Well Location: /S- ft. I cfr Yt
f-4.O i�. CO ra n i )e) ft. ft. --
Facility/Owner Name Facility iD#(if applicable) ft. ft. V.' r '`V_ :i 'T:'''
ft. ft. `
/CI'L5, - )Zcy (tft {s6N r -d •
Physical Address,City,and Zip ft. ft. 0 C T 0 6 2023
J `' e c 21.REMARKS . , I
,4;i
County Parcel Identification No.(PIN) CA , ,1 .t 11
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/lon g is sufficient) 22.Certification:
Ne.,‘,___% �i
6.Is(are)the well(s)?Ai''ermanent or 'DTemporary „2S 23
Signature ofCcrtificd Wail Contrac r Date
By signing this fin-nt,/hereby cer•rffi'that:the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes orieEklo with ISA NCAC 02C.0100 or 154 NCAC 02C.0200 Well Construction Standards and that a
ifthis is a repair,fill out known well cons!,sw/ian information 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 back of this firm. i
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
3.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. Youmay also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: ,,5 (ft,) 1
24a, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(tt�,-00.and-@a 100') construction to the following:
10.Static water level below top of casing: (ft.) Division of'Water Resources,Information Processing Unit,
If water level is above casing,use"+"
/` 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: tC' (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
t above, also submit one copy of this fortn within 30 days of completion of well
12.Well construction method: t!'%•/z C i2-)!I construction to the following: 1
(i.e.auger,rotary,cable,direct push,etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) .5j-- Method of test: .5.y5 lh t- 24c.For Water Supply&Iniectionf Wells: In addition to sending the form to
/ the address(es) above, also submit out copy of this form within 30 days of
13b.Disinfection type: /'1 Amount: Q Z.. completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources j Revised 2-22-2016