GW1--01301_Well Construction - GW1_20240229

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WELL CONSTRUCTION RECORD(GW=1) Forinternal•Use Only Print Fom1
•1,Well Contractor Information:
• Chris.King" .
14.WATER ZONES
'WellConirmiorNarn: FROM.. 'TO . '.DESCRIPTION
'.NC Well ContractorCe•,tificationNumbcr . • ft.. ft.
Aqua Drill, Inc. ' 15.OUTER CASING(for multi-cased wells)OR LINER(If a linable)
• .FROM. • TO '4 DIAMETER THICKNESS •MATERIAL
Company Name, R: I ° 'R; I / s In. _ '
0 .tin / t ! c'jz;2I Igie
16:INNER'CASING OR TUBING(geothermal closed-loop)2.Well Construction Permit#:�.� 3•• j. FROM TO DIAMETER THICKNESS • MATERIAL •
List all applicable cell constraclion pe{m(ts(i:e.U/C,Catiiny,State,Variance;etc,), • ' ft.,_ ft: in.'
:3.Well Use,(check well use): • qt, n, io..
Water Supply Well: " 17:SCREEN
� - Agrimltnraj _• • _ FROM TO : DIAMETER' SI,OT SIZE• THICKNESS- •MATERIAL .
DManicipal/Public' ft. R.:
Geothermal(Heating/Cooling Supply) $esidentiel Voter Supply.(single)
industrial/Commercial n • ft... in.3Residehtial Water Supply(shared).
Irrigation • •
111 GROUT' . -
. 'FROM • . ' TO • • . MATERIAL . '.EMPLACEMENT METHOD&AMOUNT
•NomWater Supply Well:: �, ft.• 3
Monitoring. .0Recovery. O �� -... . JuiiG - C'(r! i .s'
injection Well: ft. ft
Aquifer Recharge - . fk.. ft. .
�Grolmdwatcr Remediation• _
Aquifer Storage and'Reeovety. Salinity Battier 19.SAND/GRAVEL PACK(If applicable)
FROM" TO'•L.
. •MATERIAL• . EMPLACEMENT METHOD Aquifer:Test • , . •
StoitnwaterDrainage e.. tt.' '
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Experimental Technology' 0Subsidence Control ft.•. 2•
Geotlrermal;(Closed Loop) OTracer . . - . - 20.DRILLING LOG(attackaddltlonal sheets if necessafy)
• Geothermal(Heating/Cooling Return)• •:rlOther,(explain under#21 Remarks)' 'FROMTO DESCRW1iO (color.baraoeas salvenekfypr grain du,err:)
4,Date Wep(s),Completed: _$ .'�•C�•Well ID# O R X• O• �Q I '
•So:Well Location:.
fL : ft.. •
Facility/Owner Name .Facility ID#(if applicable) O• • ft.. 1\C r
I00 rtocc , '0.►z.. c.: • .. 'Doi ih,u•- .,C. . H. : :ft.. .
Li .. "
'Physical lAddress,City,and Zip ft. tt. v ri 2t1
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OA dI c15CJ•)1�. •
21.REMARKS 7.
County ' Parcel ldcntification-No.(PIN) l3itilnJa a
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5b:Lititude and longitude In.degrees/minutes/seconds•or decimal'degrees:.. - .
(if well field,one Iet/loag is sufficient) 22:Certttic don:.
• • - . . N W.
6.Is(are)the well(s) termanent-. or: Tern ra Siguetutro of Contractor
Po rY Date.
By signing lhts form;/.herein cerq jv t1taf tie aell(s)_aur(mem)conrtructed:ld accordance.
'7.Isthin•a repair'to;an existing well: :©Yee: or ci. - . -with 154•NCAC 02C.0100 er 15.4 NCAAC 02C.0200 Well Construction Slandel*and that a
.Iffhis is a repair,iill out koca m well construction information and crplairi due nature of the - copyofilds record has been provided to the uell'otiner.
repair under 1121 renmarkr section or an llre.back ofthls form:
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'23.$ite 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'pmvide additional well site details or well"
• construction,only I'OW 1 is needed...Indicate TOTAL NUMBER of.wells• •construction detail's.'you may also attach additional pages ifnecessaiy..
drilled: .
SUBMITTAL INSTRUCTIONS
•9.Total well depth below land'surface: •
For multiple uelLs list all drinks iifdiperent(example.3 2oo and 20100') • (R•) tea, For All Wells:. 'Submit.this form within.30 days of completion"of well
construction to the following., .: . •
10.:Static water level,below:top,of casing: • :U'°• ft. .
. . ( ) IDtv(sion of Rater.Resources;lnformatlodProcesslag Unit; •
Yurger level Is above casing,use n+^
'1617 Mall Service-Ce iter,.Raletgb,NC 27699-1617
Il."Borehole diameter (iii) •
24h.For'lniectlon•Wells: In addition to sendingthe form to the address in:24a
12.Well construction method: 1'16 0�Z .1'�' above;also submit copy of thisi form within 30 days:of completion of well. e'
:(i.e.auger,rotary,.cable,-direct push,etc.): construction •to the following. j
FOR WATER SUPPLY WELLS ONLY:. _ • • -Dlvision'of Water Resources;Underground Injection Control Program,.
i � -1636 Mail Service Center,Raleigh;NC 276994636
13a:.Y.leld(gpm). . !'/.g Method oftest: .5•i�•YJ • 24c.'For Water.Supply Bd.Inlectlon Wells:. In addition to sending the form to-
pp - ' the:address(es) above, also:submittone copy of Ibis:form withio.30 days•of
' 13b..Disinfection type:- -1- -i . -Amount: J ( Q Z'. " .completion of well:construction to the:county health departinent of-the county
-where constructed..
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Form GW-1 • North Caiolina Department of Environmental Quality-Division of WotcrResources. -Revised 2-22-2016