GW1--05801_Well Construction - GW1_20240926

1
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ^7C ft. '7 �� ft. -_30
/ ' '� t
2080-A V ['-'1l ill
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
C. ft. / ft. / i in. GG '� I /
Company Name 1' rE' (e /y J]�jz ?� i t (�'l
16.INNER CAASiNG OR TUBING(geothermal closed-loop)
qq
2.Well Construction Permit#: 6 �1 FROM TO DIAMETER THICKNESS_ MATERIAL —
List all applicable well construction permits(ie.UiC,Coutrt).State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. to
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
QAgricultural Municipal/Public ft. ft. in.
QGeothermal(Heating/Cooling Supply) EEiResidential Water Supply(single) ft ft In.
°Industrial/Commercial DRcsidcntial Water Supply(shared)
18.GROUT __
Ilirrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: /�j ft. (_G ft. J,j.4 y.. C A 1 I>5
°Monitoring ©Recovery �' ft. ft. J
injection Well: --
ft. ft.
DAquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
DGeothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color.hardness,soil/rock tape,grain sin,etc.)
°Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) .�
\ /\ ft. I. ft. / .C e 1
4.Date Well(s)Completed -1) 2 t!Well ID# // ft. %G ft. ice/C; 1 o C 1c
5a.WellC Location: + Lc ft. S-rt. h 1flL �j-fZl�ltLJ 1
SC SL, P j) Kh(`�Sc V ft. ft. ' , ./� i
Facility/Owner Name Facility IIDDJ#(if applicable)
fL ft.
H S �.a j) IZl X1 t/i C&.j Lj� / I ►15bejx
ft. ft. .. 11
Physical Address,City,and Zip I r 7 31 v11 ft. ft.
ch f l,h A o1 21.REMARKS
County 1 1 Parcel Identification No (PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certiifi'lion:
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Well Contracto Date
Br signing this/ornt,1/tereht•certiji'that the wen(s) was(were)coastnn:led in accordance
7.Is this a repair to an existing well: DYes or UllVo with 1SA NCAC 0?C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill nut known well construction information and explain the nature of the cap)'of this record has been provided to the ve!/owner.
repair under#21 remarks section or on the hack of this limn.
23.Site diagram or additional well,details:
3.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 LNSTRUCTIONS
9.Total well depth below land surface: I 'S./! (ft) 24a. For All Wells: Submit :his form within 30 days of completion of well
For multiple wells list all depths ii/diferent(example-3(a)200'and 2(a)1(10') construction to the following:
10.Static water level below top of casing: 0 (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: 6 (in.) 24b. For Injection 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: j iz 1 a ) 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) . 30 Method of test: 7 1 11 i'T 24c. For Water Supply& Injection Wells: In addition to sending the form to
J the address(es) above, also submit one copy of this form within 30 days of
/
13b.Disinfection type: /�i I Amount: J 4 0 completion of well construction to the county health department of the county
where constructed.
Fort OW-i North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016