GW1--06637_Well Construction - GW1_20231017

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King
14:WATERZONES ,- " '1. t ,_
Well Contractor Name FROM TO DESCRIPTION
2080-A ‘156 ft. t j 9 ) ft. ..3 &I pi r
ft. ft.
NC Well Contractor Certification Number
15.OUTERCASING(for:multi-cased4ells)OWLINERl➢fap licable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. 1
Company Name D elO ‘ V q, in, S D iz 21 p7.J s C
2 5 d 16.INNER�.CASING'OR TUBING(neotheemal:closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS . MATERIAL x -
List all applicable well consn'ucion permits(i.e.UIC.County,State,Variance.etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17:SCREEN''.
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
ft ft. in.
Industrial/Commercial LDResidential Water Supply(shared) -
18:,GROUT „.; -` - :i - . ' ','
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
V
Non-Water Supply Well: r'1 ft. `�70 ft. g eo:A t'-14e (Ind 17.5 .
Monitoring 0Recovery ft. aC ft. �tl
Injection Well: .
ft. ft.
Aquifer Recharge
Groundwater Remediation
19::S.&ND/GRAVEL,PACK(lf applicable) , 'k . u
Aquifer Storage and Recovery SalinityBarrier T_ °
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft. i,
Experimental Technology 0Subsidence Control ft. ft. !
Geothermal(Closed Loop) OTracer 203IDRILL^ING,IrOG(attactiiadditionallsbeetsafneeessary);`
Geothermal(Heating/Cooling Return) Other(explain under#2d Remarks) FROM To DESCRIPTION(coollor,hardness,soil/reek type.gain size.eta) ~
0 ft. ft. r2(,'Gr C_ha v
4.Date Well(s)Completed — a 9 —) Well ID# 41 ft. ft.
i
5a.Well Location: 3 ft. 3� ft. y go ce•
6)civ M'j 5 eR 5 ft. s-�5.ft. 3t eG<r `
r
Facility/Owner Name Facility ID#(if applicable) ft. ft. :..,1'!^~
56/ r)d A S iZeii 015 jZ ft. ft. 0ry
3
Physical Address,City,and Zip N vy)�C ft. ft. I, O �°2
,r� C '`21:ItEMARKS.�,:, • 1•C
Ii
Count (PIN)
fl10 t.& a 6,2, d = S e,r c ri
y P .6 1
Parcel Identification No. .�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (1J© s.k6 Li
(if well field,one lat/long is sufficient) 22.Certific 'on:
N W - 9 - 1 / - -2
6.Is(are)the well(s)permanent or *Temporary
Signature of Certified e11 Contractor , Date
By signing this fine,I hereby cert j'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ANo with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well constriction Information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. l•
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: (fa) 24a. For All Wells: Submit this form within 30 days of coin let
For multiple wells list all depths ijdperent(example-3@200'and 2@100� p y p ion of well
/ construction to the following:
10.Static water level below top of casing: fJ b (ft.) I
Ijxarer level is above casing,use"+' Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
I1.Borehole diameter: Q' (in.) 1 24b.For Infection Wells: In addition to sending the form to the address in 24a`
R above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: / j a. ((?,
(i.e.auger,rotary,cable,direct push,etc.) construction to the following: I
I
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program, •
1636 Mail Service Center,
nter,Raleigh,NC 27699-1636
13a.Yield(gpm) �� Method of test: 5)c3 h+" 24c.For Water Supply&Iniection'Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: l~)fi 1-' Amount: /4 0 z completion of well construction to the county health department of the county
where constructed.
Form OW-1 wu.a,r'_,:_ •, — -- - - -