GW1--06683_Well Construction - GW1_20231017

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 19 WATER ZONES:, 1. a -
Well Contractor Name
2080-A �F rljROM TO DESCRIPTION 70 ft. e'// ft, s' i/�f pt r'M
[
E✓C5 ft. 56/O ft. ' 1 (�'l
�C7
NC Well Contractor Certification Number
-4.5:OUTER;CASiNG(foi mu(d,eased4vells),OR1LINER(if"ep'!feeble) ‘.,' :
Aqua Drill, Inc. FROM ' TO DIAMETER THICKNESS MATERIAL
Company Name
ft. ft. in.
;'16.,INNERRCASING OltTUBING�(geotherimalelosed-loop)' `"
2.Well Construction Permit#: j� FROM TO DiAMETER THICKNESS MATERIAL
List all applicable well construction pe is(i.e.UIC,County.State,Variance.etc.) 0 ft -ft. / 1/'4 in, SDIZ q 1 p` v
3.Well Use(check well use): `, ft. ft. co in. !`
Water Supply Well: 17.SCREEN` _' -
M
FROM TO DIAMETER SLOT SiZE THICKNESS MATERIAL
Agricultural °Municipal/Public ft, ft. in.:
Geothermal(Hcating/Cooling Supply) Etesidential Water Supply(single) - ft. ft. in.
Industrial/Commercial °Residential Water Supply(shared)
.18.,GROUT .
gation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: - 0 f' 02C) ft• t;% `p hi pc
Monitoring °Recovery - ft. ft.
Injection Well:
ft ft.Aquifer Recharge °Groundwater Remediation
Aquifer Storage and Recovery19i`SAND/GRAVEL PACK(if applicable) `= ;F,
q g 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test °Stormwater Drainage ft. ft. i ;
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer '
x ZO.,DRiLLING>LOG.(attack addnhonal%§heetslf neces§ "'
a l 4 ary)a � ,. ,
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRiPTION(color,hardness,soil/rock rock type,grainsue,etc.)
,+ o ft c ft, Zed e i o y
4.Date Well(s)Completed:�l _17')3 Well ID# •- ft. 50 ft. Se riij Ro K
ft. o ft.
/� Sa.Well Loca1tion: 6a� �)i�, ��AU�'�
5$108Y RId"le Ft-rec. C)t' 1 ft. ft.
Facility/Owner Name FacilityID# ifapplicable)
ft• ft, 1^' ' ': (':i-
( 'm 4.- k,
5-6534 h.)c - 76L1 /.%Cy g1 cl,q , ft, ft. i t ~ •
Physical Address,City,and Zip ft. ft. I OCTY l 2 3
S-1-ores 21.'iREMARxs R ,. >ntn- -3 tk -
County Parcel Identification No.(PIN) �• `.�.. ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
I`
N W /`I� , -2 ! hJ
I '
6.Is(are)the well(s ermanent or °Temporary Si ature xt of Certific Well Contractor Dace
By signing this,form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes orG No with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
(this is a repair,fill out known well construction coon information and explain the nature of the copy of this record hue been provided to i he well owner.
repair under#21 remarks section or on the back 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 1
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all deptns.iildifferent(example-3@ 200'and 2@l00) construction to the following:
If10.
CII Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ij (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: /'�//� f C� 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:
i
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
p� e 1
13a.Yield(gpm) v Method of test:Si �T 24c.For Water Supply&Iniecti f n;Wells: In addition to sending the form to
`ll the address(es) above, also submit tine copy of this form within 30 days of
!�
13b.Disinfection type: 14 Amount: 16 0 Z.- completion of well construction to the county health department of the county
where constructed.
Fonn GW-1 North Carolina Department of Fnvirnnmrntnl cumin.._ciao:,..,,.cur_.-- _..____ :