GW1--04565_Well Construction - GW1_20240731

WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
I--7--
I.Well Contractor Information:
Chris King
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A .-76 ft. <7/ ft. C (.1 p I
NC Well Contractor Certification Number ft ft.
Aqua Drill, Inc. 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS M TE iv',
0
Company Name ft. IG//r ft. id.
!/_I in. Ic Div I I)i Id ; L.
/ _ 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit# �( FROM TO DIAMETER THICKNESS >IATERIAL
List all applicable well construction permits(i.e. U/C.County.State. Variance.etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
AgriculturalFROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
Municipal/Public it. ft. in.
Geothermal(Heating/Cooling Supply) 431,Residential Water Supply(single)
ft. ft. in.
Industrial/Commercial DRcstdential Water Supply(shared) - I
18.GROUT
Irr ration FROM TO MATERIAL EMPLACEMENT METHOD Be AMOUNT Non-Water Supply Well: e ft. T ft. CA
. 1t!]4�' (. 11 7
Monitoring OR�ovcn ft. ft. '� �-
Injection Well:
Aquifer Recharge OGroundwater Remediation ft. ft.
Aquifer Storage and Recovery19.SAND/GRAVEL PACK(if applicable)
0 Salinity Barrier FROM TO let 1TE.RIAL EMPIACF,JIENT METHOD
Aquifer Test fStonnwater Drainage ft. ft.
Experimental Technology OSubsidence Control It: ft.
Geothermal(Closed Loop) 'Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM T DFSCRI PTION(color,hardness,soiVrock type,grain site,etc.t
Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks)
Cft. ft. Se 1 r
d &6
4.Date Well(s)Complete �Y Well ID# 3 ft. %S L' ft. {A,N)d GG C I`
5a.Well Location: 6 S ft. fGO'c5 ft. j3 l U C i)rzA N de
ft. ft.
Facility/Owner Name Facility 1D#(if applicable) ft. ft. j . i•-
aC(C5� Jr= /nee Ct.;J4, Ffi 9 it'd i / c ft. ft. 3 I 2024
Physical Address.City,and Zip ft. ft.
Y,F1:.
(z II Ki c c 21.REMARKS
County 1 Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lat/long is sufficient)
22.Certifie ion:
N W
6.Is(are)the well(s) Permanent or DTemporary l naturc of Ccnitic Well Cuntrec or - 6
Si
Date
Br signing this firm,/hereby certi/P that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or lNo with 1SA NCAC 02C 0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
if this is a repair.lilt out known well construction information and explain the nature oldie copy of this record has been provided to,'Ile well owner
repair under#21 remarkc section or on the.back of this/ant
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 1 GW-I 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: C (ft.) 24a. For All Wells: Submit :his form within 30 days of completion of well
For multiple wells list all depths if different(example-3(ry200'and 24000')
construction to the following:
10.Static water level below top of casing: LI 0 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use +- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
,,A�
12.Well construction method E)12 y I 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:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground injection Control Program,
,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) C Method of test: i`r�/)1 4 24c. For Water Supple& injection Wells: [n addition to sending the form to
!i- the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: /r� (y-! Amount: I C' C •7- completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Envtmnmental Quality-Division of Water Resources Revised 2-22-2016

4 IP
HEALTH DEPN
-• ' Vi1 awith lr4p
ORANGE COUNTY ENVIRONMENTAL HEALTH SERVICES DIVISION
ONSITE WATER PROTECTION SECTION
REQUEST FOR USE OF THERMOPLASTIC CASING
TO CONSTRUCT A WATER SUPPLY WELL
Property Address: 306S'_ u T' LAjo 1 c -T-r,� �,1�..L £f1 and; 1J C Z 72143
Well Contractor Name A ra. Drill / _L.fc OCHD Well Permit#: W Z
Contractor Registration No02 O -)9 Property PIN: 984 6 G 3L�85"
REASON(S) FOR INSTALLING THERMOPLASTIC CASING:
1.
2.
3.
4.
5.
Well Owner Name: A/, ' he.... 4 7' / P c�
one
Well Owner Signatur Date: 7 /z.n 2 zy
Well Contractor Signature: f%�L; t.�
Date. a1/ oZ
919 245 2360 • 131 West Margaret Lane. Suite 100 1 Hillsborough, NC 27278 orangecountync.gov