GW1--04499_Well Construction - GW1_20240730

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only - '-'--
1.Well Contractor Information:
Chris King _
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A 65 ft• 7 ft. `2 &, r, r '
NC Well Contractor Certification Number ft. A�%� ft. '� i 1� al
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Aqua Drill, Inc. FROM TO It DIAMETER THICKNESS MATERIAL
Company Name ft. L) ft. I I,A in. ; I 7S .! I -1,1)6,1
�J--�'� 16.INNER CASING OR TUBING(geothermal closed-loop)
L;
2.Well Construction Permit 4: / 7 L) FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County.State.Variance.etc./ ft. ft. in.
3.Well Use(check well use): ft. I ft. in. 1
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
®Municipal/Public ft. ft. in
Geothermal(Heating/Cooling Supply) esidcntial Water Supply(single) = f i
ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. a C ft. f3 ie,,4-n k CO t N _S}.)`
Monitoring nRecovery ft. ft. 1J f1 1
Injection Well:
Aquifer Rechargeft. It.
qGroundwater Remediation
Aquifer Storage and Recove 19.SAND/GRAVEL PACK(if applicable)
ry DSalinity Barrier FROM To MATERLLI. EMPLACEMENT METHOD
Aquifer Test OStonnwater Drainage ft. ft.
Experimental Technology (Subsidence Control ft. ft.
Geothermal(Closed Loop) 0Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under r#21 Remarks) FROM TO DESCRIPTION sensor,horsiness,soil/rock type,gain size.etc.)
(7�j � ft. -2) ft. 7 C�( 1
4.Date Well(s)Completed: ( Js',?fq Well ID# 3ft. 0,,71 ft. a 1;L(j C r..,
5a.Well Location: ft. ) ft. 1. o
"LI
311 +A ft. ft. !. .♦.,
FacilityiOwncr Name Facility lD#(if applicable) ft. ft. JUL 3 0 2024
3 S G Pe rz- ail f R 1.)41-sb o iZ o , i•1. Ci It. It.
Physical Address.City,and Zip It. ft. }try
C'{14-1 - /9 1n 21.REMARKS p_nn pp y� , p
County Parcel identification No.(PIN) 40116 ._I-•l2.C/ ! V ��A) A-4 l..j.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W -�647# -/� '/
_� [
6.Is(are)the well(s) ermanent or Temporary Signature of Certified well Contrac r Date
g),signing this tarot,/hereby certify that,he swills)was(were)constructed in accordance
7.Is this a repair to an existing well: (Yes or gtNo with/5A NCAC 02C 0/00 or I5A NCAC 62C.0200 Well Construction Standards and that a
If this is a repair.Jill out known well construction information and explain the nature of the copy of this record has been provided to the well owner
repair under#2l remarks section or on the hack 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
R.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:_
g5 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this fo:m within 30 days of completion of well
For multiple wells list all depths If different(example-3(6;200'and 2(aU100)
construction to the following:
1If m Static water level below top of casing: 0 (ftJ Division of Water Resources,Information Processing Unit,If muter)eve/is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
.^ above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: �"'1 I d-IZ; ) 1 construction to the following:
(i.e.auger,rotary,cable,direct push.etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) )L'Ci Method of test: •J 1 q 1 r)- 24c. For Water Supply & Injection 1A'ells: In addition to sending the form to
/ the address(es) above, also submit one copy of this form within 30 days of
M 1413b.Disinfection type: ' Amount: ./ (, C 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