GW1--06682_Well Construction - GW1_20231017

WELL CONSTRUCTION RECORD(GW-1) - -- - =- _-
For Internal Use Only: r
1.Well Contractor Information:
Chris King
14 WATERZONES _:- ,I,-1 --
Well Contractor Name FROM -TO DE CRIPTION
2080-A ,27 2 ft. ,0271. ft, I
m.
NC Well Contractor Certification Number ft. ft. I
Aqua Drill, Inc. 15:OUTER'CASING(for multr caseduvells):ORLINER:(if'ap'licable) _ '
FROM TO DIAMETER THICKNESS MATERIAL
Company Name ' in. C O C
ft. I C� ft. �/� I,)IIfZ .Z� ,. �i'(��l
�//�/ =16.INNER CASING`OR:TUBING'(peothermal-closed-loop)' ,,-:: .„ ,
2.Well Construction Permit i• FROM. 'TO DIAMETER THICKNESS ' MATERIAL
List all applicable tie!!construction p sits(i.e.UIC,County,State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17s'SCREEN -
A cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) aiResidential Water Supply(single)
ft. ft. in,
Industrial/Commercial Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 7 20 ft Pe 4i� 6 t ps
Monitoring Rccovery (..� f• a ft. h
Injection Well:
Aquifer Recharge ft. ft.
9 rS DGroundwater Remediation
-,19:=SAND/GRAVEL-PACK(if applicable) `;• -
Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. - ft. I'
Experimental Technology °Subsidence Control ft. ft. I
Geothermal(Closed Loop) 'Tracer :20.FDRILLING;LOG(attach;additional:she if necess
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)*r
Geothermal(Heating/Cooling Retum) nlOther(explain under#21 Remarks)
y/
i
4.Date Well(s)Completetl�-`j =CCO�'L3 Well ID# ft. ft. qt
� �[S 5Aru�1 Zo c(C
5a.Well Location: ft. ft.
�a 5 l3Ioe Gnxtm;le
- 1 I,a- ) ft. ft.
eFaci fry/OwnerNamc /v
Facility iD#(if applicable) ft. ft. u,r .', y';; • •-
�q C �+),p 1 �+ �` • 1. pf :' �.T q~ ,5
2L [7 J-k I(. U 5 v . g f9 C. tux ft. ft. (�
' Physical Address,City,and Zip ft. ft. i O C T 1 ( 2023
5 (3re 5 ,21i REMARICS,,.: °. .- , ,3 ,, :., r
County Parcel Identification No.(PIN) I [},,.,;_:
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certification:
N
_24 6.Is(are)the wells ermanent W n naturCDi3O or OTemporaryg rttficd,Z,.....:i.., X..:
Dktc r
i By signing this Arm,I hereby cettf'that the nell(s)was(were)constructed in accordance
7.Is this a repair to air existing well: DYes orio 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 construction 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 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
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only I 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: .30 S (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-,3(th200'and 2@100')
construction to the following:
10.Static water level below top of casing: td Q (ft.) Division of Water Resources
If ,Information Processing Unit,
water level is above casing.use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: /�I/Z ��zt,`1 f 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
q. c
13a.Yield(gpm) Method of test: S i�'j.pi 4. 24c.For Water Supply&Iniection Wells: In addition to sending the form to.
L` l( the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: k.-Vi H Amount:f C 7—.. completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016