GW1--05942_Well Construction - GW1_20241009

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 , p 9 0 ft. t Li ( ft- S Cji-, e t i-rx
1(7s- n• ,rG ft. `5' 6-t )a I ty-1
NC Well Contractor Certification Number
15.OUTER CASING'(for multi-cased wells)OR LINER(if all licable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0
ft. c 4? ft. 6I/- in. t( SS &A I,J
Company Name 4
C p •' U 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:✓ //q Wr e)..(i�� l FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.U/C.County.State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM _ TO _ DIAMETER - SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) (residential Water Supply(single) ft. ft. - in.
IndustriaUCommercial JResidential Water Supply(shared) 18.GROUT .
Irrigation FROM TO • MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 0 B. r14-N;NC (_,_k,,�.v S
Monitoring DRccovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge IDGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery EjSalinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test ID Stormwater Drainage_ ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) 0Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soiprock type,Grain etc.)
CN ft' la ft ,fed CI A y
4.Date Well(s)Completed:,®"7.57a9 Well ID# )a. ft. d 0 ft. 5/grid j7_G I
5a.Well Location: 0 ft. (i�SS-ft slue 6..f..0 W 0,e
ft. ft 6.771
ft. a t.,.. x.,...,.. .; 'v 1... _:
Facility/OwnerfY Name Facility iD#(if applicable) OCT
�f rI
I 1 1 ge A iIvo) c.* ft ft 1 I1,T 11 . ?11?4•
Physical Address.City,and Zip ft. ft.
bq141 C a 21.REMARKS It,.:..,,:,zL-'' •.. ...;, .;,e
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.Certification:
N W -LZVI /0 -3--2 ((
6.Is(are)the well(s)ElRer'manent or Temporary Signature of Certified Well Contractor Date
By signing this form,i hereby certify that the well(s)was(iverel constructed in accordance
7.Is this a repair to an existing well: jYes or ONo with ISA NCAC 02C.0100 or ISA 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 cop)'of this record has been pmvided 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 I 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: c- (f.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(([different(example-3Q l'200'and 2@1001 construction to the following:
10.Static water level below top of casing: ® (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: (p (in.) 24b.For injection Wells: In addition to sending the form to the address in 24a
• +1 ' e above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: fi 1)Z C:IZ i 1 1 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSyy�� ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) v Method of test: Shte 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: //-1/-4 Amount: //6 6 completion of well construction to the county health department of the county
where constructed. I
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016