GW1--05024_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 1 IS-ft. ii ft. / 6 (-i I�.
rn
NC Well Contractor Certification Number
7a ft. /?/ ft. -1 �t M
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESSj MATERIAL. /
0 ft. 5,0 ft. J /(<in. i I �/g &n l V
CompanyName l� "
�] I ) t J„�,_ I ., 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: / `.JL )1) FROM TO DIAMETER. i THICKNESS MATERIAL
List all applicable well construction permits(i.e. WC,County.State.Variance,etc.) It. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) $csidcntial Water Supply(single)
f[. ft. in.
industrial/Commercial 0Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ( ft. �`0 ft. i Ai;� r{k i;es
Monitoring f Recovery ft. �C ft. i l
injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
Aquifer Storage and Recovery19.SAND/GRAVEL PACK(if applicable)
S
tI $ 0Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) 0 Tracer 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 gain sic etc.)
o ft. 6 ft. Re,' clry
4.Date Well(s)Completed: 1) -Q'IWell iD# .1- 99, 6 It. cis-s- ft. A i,V c1 �c C k.
c
5a.Well Location: %.,11 c ft. '1 OS-ft. ku 13 c /(r tz A iN i 4
ft. of ft.
. s.-.
Facility/Owner Name Facility iD#(if applicable) ft. ft.
!'I i G L 'I ?OM
1`1l b 12 e'Ad;-tf,q c -t KeirLdil®dl lC 1ri►.yli N�{
Physical Address,City,and Zip t ft. ft, fX
il i I A M t0�i N (C' 21.REMARKS W.
County Parcel identification No.(PIN) _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lat/long is sufficient) 22.Certifica 'on
N W
024-- --•t'- g').2 - 1 9
6.Is(are)the well(sPermanent or Temporary Sigma re of Certified ell Contractor Date
By signing this fonn,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EjYes or RiNo with 1SA.NCAC 02C.0100 or/5A,NCAC 02C.0200 Well Construction Standards and that a
If this is a repair.ill 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:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
I� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: d (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(ru 200'and 2(a3100')
3construction to the following:
10.Static water level below top of casing: 6 (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 Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: )17 ��1 1 / above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary, construction to the following:
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
`
132.Yield(gpm) Method of test: `}j a 24c.For Water Supply& injection Wells: In addition to sending the form to
1 the address(es) above, also subm t one copy of this form within 30 days of
13b.Disinfection type: Amount:/6 el 2. completion of well construction to the county health department of the county
where constructed.
Form G W-I North Carolina Department of Environmental Oualitv-Division of Water Recnnrees