GW1--05020_Well Construction - GW1_20240827

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 2 6 ft. 7 ) ft. 16 i i >
poi
NC Well Contractor Certification Number I(-4 0 ft. 1 y Z. 10 /••t t••�
15.OUTER CASING(for multi-cased`wells)OR LiNER(if an livable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
/�}ft. ft, f�)j 15 in. , 1 S g' 6_yn) : /
Company Name v ` /I V
�f��•a I y� ` 16.INNER CA3 G OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#:S / get..)G 1-1 v (J( I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. U/C.County.Suite.Variance,ere.) ft. ft. in.
3.Well Use(check well use): R. ft. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETEN. SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public L.Iunp ft. ft. in.
Geothermal(Heating/Cooling Supply) 2kcsidential Water Supply(single) ft. ft. in.
0 Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
(,irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 0 ft. 'L �J' Y e t,v,o}C ,i ,' >
p C
Monitoring 0Recovery ft. ft. > -
injection Well:
ft. ft.
'Aquifer Recharge 0Groundwater Remediation
uifer Storage and Recovery19.SAND/GRAVEL PACK(if applicable)
A
q g 'Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
QExperimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color hardness soil/rock type,grain sits,etc.)
i II ,�, ern ft. f:
4.Date Well(s)Completed: L2-,2 `Well ID#/.�C.1 f 6 9 c ft. S J
ft. A,. �•1 17� Q V
�
5a.Well Location: S--ft. !1c C . 1t 0 I()c 16rZ A Kik i e
ft. ft. j
Facili /OwncrNamc ft. ft 1 tY Facility ID#(rfapplr eblcl
j 5)7 IZ e cs r C+ ar e ruNio d l t /,.A,I.il.i NA ft. ft. Q ll G 2
Physical Address,City,and Zip ft. ft.
AlyifrIANce 21.REMARKS . '
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lakiong is sufficient) 22.Certification:
6.Is(are)the wells Lermanent or ID Temporary Signature of Certifi Well onuado Datc
By signing this(Farm, i hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or Ako with 15,4 NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this 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#21 remarks section or on the back 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 1 GW-1 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: 1 Is_ (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3©200'and 2@1000
construction to the following:
10.Static water level below top of casing: 3 O (ft.) Division of Water Resources,information Processing Unit,
If water level 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
12 Well construction method: P 1 /(� R` ( above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary, construction to the following:
g 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,.1 Method of test: 5i(,i VI•}- 24c.For Water Supply& Injection Wells: In addition to sending the form to
' 1 T /(d "� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: /-4 / Amount: 1 0 'Z, completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources RPo cavi'_")"_9oii.