GW1--07617_Well Construction - GW1_20231204

. •1.Well Contractor information. . • - .. .. .
' For Internal•Use Only' �
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: .Chris King•..: _
.Well'Contractor Nerve
14.WA
�. . .. .. .• :.' ': . . FROM TER?�NES . _
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2080A •. ..- •- : • • -' S9t?ft
NC Well Contractor Ce '
DESCRIPTION .
. - rttfcation Number•. '
'Aqua Drill,Inc. . :. -
CASING for �
ISi OUTS
mpanyName . ' '• ,.•.
6� mW
FROM R` f
® ft: TERIAL'.
use weds
DIAMETER•'
• 2.Well Construction Permit#:': 9.' : ' 3 - •': 16,1NNER CASING.OR TUBING :eotbe -t
MA
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7�
,i,��O.V 'FROM T DIAMETER•: THICKNESS
List all"Nimble ail/couslirctlon permits(t.e.U)C Cougt};State.Variance etc). (G • •
3 WellWelt Use(check well-rite). .
MATE•
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R1AL•
Water Supply:WeD:.
• .. -17:SCREEN' :
Agricultural . . •
... 1/Publ.
.. • • � � ictpa tc.
M
. . Geothermal(Hcatra CoolingSu 1 ' •
• FROM TO '
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g PP y) tdcntiel WatorSu' 1 sin Ic). : '
ft
. IndustriaUCo - Y( g : . , .. _
. R - D AMErEp
131
er�,, �i
ti�i' � .SLOT _ • -
517� TH[CKt1'ESS
mmncrcial'
..• Rcsidcntial Watcc 5 _ 1 sh
'L.lr. .. . . uPP Y(. arcd)_ . .. • In,;
gation .. tS:GROUT '-.
: : No4-Water.SuPP1Y Well. •
FROM • TO MATERIAL EMPLACEMENTMHI.HOD&AMOit
Injection Well: : .. . : -
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�Aquifeir R6ch .. . .-- .. .:. .. .. . . , • -
e •- A .f fr �Goundwater Remediation .. -If' �: • • • • • '
. . '�, qw. Storage and Recovery.• :.oSalinity Barnet' '19.8AND/GRAVEL:PACK a 'licable
bAquiferTest.. 0Sto -
rmwaterDrainage ; rH'fi tl. :M
'' '•' FRo
TO' ATERIAI
Ex enmentel Technolo ••' - .. .� : _ ED!. , : '. `.�SubsrdenceControl' . .. . _
RMPLACEt►rE11T METHOD
. ::-Geothermal(Closed I:Oop) � Tracer' ......:-.....•...::.:. - ''. .� � -.:.
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@!� . . �•. " �. 20-DRLLLING LOG(attach additional abeeb if n •: .
DGeothermal'(Heaheg/Coolmg'Retum).'. . Other a lain:under621 Remarks).' FROM_.•- -To )' • •
( %P DESCRIP770N(eolor'haninessiwWisck
:.•::'‘.•.:::,.•-.. .•-•. :••"1:• . :-:•.:• •-.: ••.. ••i.:. 1 ..•.•. •.•::-:•-•:.-..•...:-:-: •-'.•. •:.I: :-•• t.•.:--.1.i•v ri••-•• : : A)1O4‘;••.•:_0:1:._::1f.36b 6.•.5: ;•-••-"ftt7.;•.•<.:•F0Aiem-6d,.a&•;..•.;...c6-1i 2 iep i g-•,h: ):••.1..4.•.••.•C-..;fuse,pratneire,aNa)- .
: 4.Date Wel(s)Completed) .iZ cl Z -
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Well'ID#K C ft
C�
.5a.Weil Ocati011S. - . ; .
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ft. ft.
Faciiity/Owner amc • Facility log(ifapplicablo)'-. ' B ft.. ) s
1 A11t
.. .Physical Address,City,and Zip. � � : ii .-
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uL�.
r . : .. • • • •• 2a
'• '7 f • • �. County:. I •• • • • 2EMAR1{g
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Parcol identification'No.'(P
. Sb..Latltude and longitude tin:degrees/minuteeseconds or decimal degrees::- . : •' '
(if well field,one lat/long'is sutfcient).' :' ::
22.:.Ce • •tion:
I N.:
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'- , 6.Is(are)the wel!(s) ertnanent:' or. Temporary .. . . Signatunc.of Ccrt' cd Well Con or Flaw..^�
'• By signing Ihls form,I herehp.cer:(/1 that the we/l(s)was(were),convtnteted1n accordance..
7 Is this a repair to an existing well:. Yes or Aphis). •- .with 13A NCAC O2C.0100 or 1Sd.NCAC.02C.0200 Well Construcupn Standards-and that a,{lads is'a repair,'fill out known well constntctloti lnfommtlon'and explain the;Owe(tithe copy 0th/iL,trc(rd hus peen provided to lbe:well owner.
repair under 1121 retitarltssection or on tik.beet of thty form. : • •• • • • • •• ' ' -' • -• ' •• • - '
• I : • -: . . : .' 23.Site diagram or additional well details: • • •
- 8 For:Geoprobe/DPT or�Ciosed-Loop Geothermal Wells having the same • : '- You may use the back of this page to provide additional well trite details or well' . '
., construction;calif 1 GW-1 is needed..Indicate TOTAL NUMBER of wells .. ' may also attach additional pages if necessary.
drilled:
constnretion details.You
p :(ft.)..-.
• SUBMITTAL;INSTRUCTIONS . '
- 9 Total well depth below land surface -I 0 Q 57 ' ' ( ) .•24a.•For All Wells Submit this form within 30 days
Formuliipfe wellslist all depths{f dj :rent(example-3(a)200 and 2(a)100) -` y, of•completion of well'
ft.
constriction to the•f
10.S•tatic water level below top of casing: ' ' _ (f1,).
I10.St levells cbtive casing,axe op - `_ C ces;InformatiOn'Processing Unit,
Division of Water.Res
1617 Mail Service Center,Raleigh,NC 27699-1617 •
•11.Borehole diameter: '.(in.) . . ' .: ' ;. . - � '
- • • .. 24b.Igor Infection-Wells:. In addition to sending the,font to the address in 24e• • .. :
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12 Well construction method 1 1 I: 'd i it ,'I cone,also submit one copy•ofs;omi.withi'"." -ays of completion•of well
(i a auger,rotary,cable,direct push,etc,). .' . ' - ' - ., • -
' .' : •- , construction to the'followmg..
•. .WATER SUPPLY WELit••ONLY: - d Injection Contro l
Division of Water,agonies Unde nn' o Program,:. '
�. • :. - .. 1636 Mail Service Cei ter,_Raleigh,NG 27699-1636
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.13a,Yield(gpm)-:I �`; . . '• .Method'of test •'-U-h_•-1- : ' 24c.For Water Sunoly•&Iolection Wellsi In addition CO sending the form.to
i f .• -Z' : • the-address(es) above;.also.submit;one copy•of`this,form within 30 days;:of
13b.Disinfection type:•[�T/7 : • ' : ' Amount:2.� •• . completion of well construction to.the county health.department-of the county_
•-- constructed. • '
where
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Form GW=1 • , ' . North Carolina Department of Environmental Quality=Division of Water Resoumc • -20
- ' Revised 2-221.6