GW1--05017_Well Construction - GW1_20240827

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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 fit. a66 ft. /0 i pir-1
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM TO DIAMETER f TH/ICKNE S MATERIAL
Company Name Q ft. ( i 3 ft. 16�, in. 1 1/ 6 o �•0))
L) J - 16,INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 7 e� FROM TO DIAMETER I THICKNESS t MATERIAL
List all applicable Ice!'construction permits(i.e.WC.County.State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Waleater Supply Well: 17.SCREEN
W
cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
®Municipal/Public ft. ft. in.
Geothermal(Hcating/Cooling Supply) ag&csidential Water Supply(single)
R. ft. in.
Olndustrial/Commcrcial fRcsidcntial Water Supply(shared)
18.GROUT
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. 6 ft. 13e, ,1iv1 ,C �1_ '1,5
Monitoring DRecovcry ft. ft. ElCiv/ 7`' 1'i
Injection Well:
Aquifer Recharge ft. ft.
g OGroundwater Remediation
0A uifer Stora a and 19.SAND/GRAVEL PACK(if applicable)
q g Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
0 Aquifer Test DStormwater Drainage ft. ft.
0 Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
QGeothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil rock tppe air size,etc.)
Cl ® ft. / ft. OQ L
u
4.Date Well(s)Completed: / -) I Nell iD# / ft. 3Q ft. libti cl S c LI
5a.Well Location: 35 ft. 2 g•j ft. .e- �( p
J'lzl�ri)•4 l..
ft. ft.
Facility/Owner Name Facility Ins(if applicable) ft. ft.
1060 .0(4).8 re.-4,) Pl ig h 5 , 0! Rc, ft. to t o
Physical Address.City,and Zip ft. ft.
7 p,�
,n g, -' e •
21.REMARKS
County Parcel Identification No.(PIN) 4'ct'`•r1 a,�;j
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lat/long is sufficient) 22.Certification;
N W ._
6.Is(are)the well(s)Ckermanent or OTemporary Sig re of Certified Well Contra r Date
By signing this form.I hereby certifi•Mot the well(s)was(were)comvnicted in accordance
7.Is this a repair to an existing well: QYes orrNo with ISA NCAC 02C 0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
!Phis is a repair,fill 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:
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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
C SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: O J (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii different(example- 200'and 2(dt100')
construction to the following:
10.Static water level below top of casing: C2 0 (ft.) Division of Water Resources,information Processing Unit,
If n'ater level is above casing,use"+•'
G1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For[niection Wells: In addition to sending the form to the address in 24a
12.Well construction method: 1 R 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) 1 D Method of test: J iGin-t- 24c. For Water Supply& injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: J /Amount:/ Q L completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Oualiiv-Division of Wnuc aa,.,,.,.o. - -