GW1--00415_Well Construction - GW1_20240116

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
Chris King
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A i i5ft' ),, R' 020 &AM
R, rt.
NC Welt Contractor Certification Number
15:OUTER CASING(for multi-cased wells)OR LINER(If ap licable)
Aqua Drill, Inc. FROM TO. DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 5C) ft. ‘Yg• In: i/33 I /pi lu
^� 16.INNER CASING✓`� OR TUBING(geothermal closed-loop) U
2.Well Construction Permit#:( / 3 4)c .2 3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.U/C,County.Stale.Variance.etc.) Is, ft. In. .
3.Well Use(check welluse): R. fr. In.
Water Supply Well: 17.SCREEN
DDAgricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
gn OMunicipal/Publio ft. ft. In.
OGeothemial(Heating/Cooling Supply) aesidential Water S Rupply(single)
tt fr. in.
Industrial/Conunercial OResidential Water Supply(shared)
.18..GROUT
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: SC) R' /)0 R' )3 Lo�N� d.in;ps
OMonitoring ORecovery ft. pC ft.
Injection Well:
fr. "t0Aquifer Recharge` OGroundwatcr Rcmcdiation
Aquifer Storage and Recovery19.SAND/GRAVEL PACK(It applicable)
OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD Aquifer Test OStormwater Drainage R, ft
Experimental Technology OSubsidence Control R ft. '
OGeothermal(Closed Loop) T racer
O 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) FROM". TO DESCRIPTION(color.hardness.saiUruek type,grain size,etc.)
�' 2 .6 ". .6 R- 5611
4.Date Well(s)Completed:, 5�Well ID# TL I L. ft 95" ft• Situ;c1 j?B C J
5a.Well Location: Sft I Y�tI7t. 13)ue i4e
ft.. ft. /te a ^a
y tar.It f--f t; I-....
Facility/Owner Name Facility IDtt(if applicable) R. ft. -' e'r .L0Is i i 0
e(70 V ,-o rid "Spfcs P1 ft. R. , JA.N 1
Physical Address,City,and Zip ft. R. " 2024 ft
04/14,7NUCC. 21.REMARKS Inivrr-%ttile..l iir.:;:.. a-. s
County k"'�2 1
Parcel Identification No.(PIN) �v `-�+
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat./long is sufficient) 22.Certifications {
N W //1
l .-.2- 2 Y
6.Is(are)the well(s)r $ermanent or Temporary Signe tc of Certified Well Contracto Dam
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: OYes or ONo with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
if this ie a repaii;fill out knmrn well construction information and explain the twiny of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of tits 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 I
9.Total well depth below land surface: (ft.) �
For multiple wells list all depths ifdderenl(example-3@200'and 1@1000 24a. For All Wells: Submit this form within 30 days'of completion of well
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construction to the following:
10.Static water level below top of casing: S O (ft.) Division of Water'Resources,Information Processing Unit,
If water levels above casing.use'JJ+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: CO (in.)
J 246.For Injection Wells: in addition to sending the form to the address in 24a
12.Well construction method: / C.2 J / 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:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: . 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 10
Method of test:_5•Iq�� 24c.For Water Supply&Injection Wells: In addition to sending the form to
I the address(es) above; also submit Opel copy of this form within-30 days of
13b.Disinfection type: � 7°/ Amount: 1 (2 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
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