GW1--00400_Well Construction - GW1_20240116

WELL CONSTRUCTION,RECORD(GW 1) Print Form,:_
For Internal Use Only: IF M1—
1.Well Contractor Information:
Chris King
la:WATER'ZONES -
WoIIContmctor Name FROM TO DESCRIPTION
2080-A. ft, )s(/ft.
NC Well Contractor Certification Number ft' ft.
Aqua Drill, Inc. ' 15.'.OUTER'CASING(formultlxased'•ivetls)OR LINER Ora licable)-
FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. %/ ) In.
IN
C- i ji i
2.Well Construction Permit#:tli 7 I W C - 16.INNER.CASING OR TUBING(geothermal closed-loop) -
FROM TO DIAMETER, THICKNESS- -'MATERIAL
List all applicable well constnrction permits:p e.UIC County,State.Variance.etc.) ft ft. i in.
3.Well Use(check well use): ft. ft. In.
Water-SupplyWell: _17.SCREEN , - •
tAgricultnral FROM TO DIAMETF,R SI.OT SIZE THICKNESS MATERIAL
13Municipal/Public ft ft. In:
.:Geothermal(Heating/Cooling Supply); Residential Water Supply(single)
Industrial/Cotnmercial ft. IL in
Residential Water Supply(shared)
Irrigation 18.GROUT
FROM TO - MATERIA EMPLACEMENT METHOD&AMOUNT
Non-Water Supply.Well: Q ft. p a rt. IQ }�j, t , c C
011Monitoring 0Recovery k/ }¢ C�it,✓ J C.
ft. ft.Injection Well•
0 Aquifer Recharge ()GroundwaterRemediation ft. ft.
()Aquifer Storage and Recovery Salinity Barrier 19.'SAND/GRAVEL PACK(if applicable) -
FROM TO MATERIAL. EMPLACEMENT METHOD
AquifeirTest 0&am eter Drainage R. rt.Experimental Technology 0SubsidenceControl n• R. -
Geothermal(Closed Loop) �}},,Tracer i
l_f 20.DRILLING LOG(attach additional sheets if necessary):
Geothermal(Heating/Cooling Return). Other(explain under Remarks) FT'OM TO' DESCRIPTION,(color,hardam solVrocicfipe,grain size,tic.)"
��yy _ 0 D.- 3 R. So
4.Date Wells)Completed: Well ID
.3 .....,2 #I .2� �A Mud
3 ft. aC.^L U I ud 4y-nli7
Sa.Well Location: ft. R• �..,
ft• • ft. v r L�.,,d c-...�, Y y 34.:: j
t 5L. y 5
Facility/Owner Name Facility iD#(if applicable) ft. ft.
72i L.,eit d y P.J. �u r� a 024
Physical Address,City,and Zip ft. ft.
IFltiv'tCT�,i1?il err
14hi N'4)Ce 21.REMARKS .,. f.".w- "''. �.rES
. �NC1ea
County Parcel Identification No.:(PIN)
Sb.'Latitude and:longitnde in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certification:
N W r
6.Is(are)the well(s) rmanent or Temporary•
Signature of Cart led Well Contractor r
Date
i;
7.Is this a repair to an existingwell: By signing this form,I hereby certlfythat the'aell(.c)was(were)constructed.in,acco dance
NI Yes o 'lo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
if this Is a repair,fill out known well canstruction information and explain the nature of the copy of this record has been provided to t/exell owner.
repair under#21 remarks section or on the back of thisform.
'23.Site diagram or'additional.well details:
8.For Geoprobe/DPT,or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional'well site details or well
construction,only OW-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: �( (ft•) 24a. For All Wells: Submit. this form within 30,days of completion of well
For multiple wells.list all depths ifdi,jJerent(example-3 a@200'and 2Q100')
construction to the following:
10.Static water level-below topof casing: i•
If water level is shove easing,use' ^ (ft.) Division:of Water Resources,Information Processing Unit,
1617 Mail Service:Center;Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) I,
/� 11 24b..Far Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: _. ;2 O 1 %t_ above,also submit one copy of this florin within 30 days of completion of well
(i.e.auger,rotary,,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,FOR WATER SUPPLY WELLS ONLY: yy� 11 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ! 0Method of test: 1 G/'i T 24c.For Water Supply&.Itiiection Wells: In addition to sending the form to
the address(es) above, also submit onel copy of this form within 30 days of
13b.Disinfection type: 4 r b.. Amount: iG 6 Z. - 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 Revised 2-22-2016 •