GW1--00397_Well Construction - GW1_20240116

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: j , _
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A (o,Y• •1414 ft. 5 6iiiiin
ft. ft. i
NC Well Contractor-Certification Number f
.15.OUTER CASING,(for multi-cused,wells)OR LINER gap llcable)
Aqua Drill, Inc. FROM TO DIAMETER 1 THICKNESS MATERIAL
fA 92. ft. l,7y In. ' , I�,o/t)
f
Company Name w �
Q 16.INNER CASING OR TUBING(geothermal closed-loap)
2.Well ConstruetiOn Permit#:/1 /06)a rti 23 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable null construction permits(i.e.(JIC,Coanq•,State.Variance,etc.) ft. R. , In.
3.Well Use(check well use): R. ft. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural Q Mull icipa1/Public fr. ft. In. •
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. R. In.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT '
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft. AO ft• 9t Thur 4c C/Nt p
Monitoring Recove T
Injection Well: rY • ft. ft.
Aquifer Recharge R. ft.
4 g OGroundwatcr Remcdiation
Aquifer Storage and Recovery Salini Barrier 19.SAND/GRAVEL PACK(if applicable)
ty FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stornwater Drainage ft, ft.
Experimental Technology IOSubsidence Control ft. ft.
Geothermal(Closed Loop) QTracer 20.DRILLING LOG.(attach additional sheets If necessary)
Geothermal(Heating/Cooling Return) Other(explain,unddeyr�#,21 RRemarks) FROM TO DFscw ION(Oiler.hardness.solurackt}pe grain size.etc.)
PVT t ` O ft 1/q_/� ft. gel Crp y r
4.Date Well(s)Completed:.) -S-2.9 Well ID# fo ft• 10 ft. 5pnid /4 G 1�,,
5a.Well Location: AO ft• 3o5-ft• ,2!tie /�diu 14
C
ft. ft.
Facility/Owner Name Facility ID#(if applicable) • ft. ft. " ` O i ;i.,,�.r.,
97,20 In o rZ J •5 P ft. ft. ; JA N 1 As
201
Physical Address,.,t City,and Zip ft ft. t
AI4/M/i�CC 21.REMARKS i)tr3:a?^r^4_, ^')/•w5
County Parcel Identification No.(PIN) Wy� a,z
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W
6.Is(are)the wells) rmanent or IITemporary Signature of C 1cd Well Contractor Date
By signing this form,.I hereby certify that the ur/l(s)was(acre)coast,acted in accordance
7.Is this a repair to an existing well: DYes or, No with ISA NCAC 02C.0100 or ISA NCAC 01C.0200 Well Construction Standards and that a
if this is a repair,fill out knots',tvell construction information and explain the nature of the copy of this record has been provided to the Well owner.
repair under#2I 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 I GW-I 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: 3 0 (ft.
con. For MI Well Submit this fort',within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 3QI00.) construction to the following: 1
10.Static water level below top of casing: ca (ft.)
Division of Water Resources,Information.Processing Unit,
If ureter level is above casing.tree.+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (In.) I.
24b.For Infection Wells: In addition to sending the form to the address in 24a
/y d�;, 1 above,also submit one copy'of this form within 30 days of completion of well
12.Well construction method: /" construction to the following:
(Le.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centier,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 1(h '� 24c.For Water'Supply&Injection Wells: In addition to sending the form to
' / the address(es) above, also submit oriel copy of this.form within 30 days of
(1 13b.Disinfection type: 7-/) Amount: /6 a Z. completion of well construction to the county health department of the county
where constructed. ' 1
1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016