GW1--05986_Well Construction - GW1_20241009

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: '
1.Well Contractor Information: . 1
Chris King 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 2) rt. 11 6 ft. 5 �,, P/i)
2080—A Ago ft. j�2 ft. •) 6,!9 7y b rt
NC Well Contractor Certification Number 15.OUTER CHASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Aqua Drill, Inc. /' j(
6 ft- 6 2 ft- �, l'/g ia. 7 P g V 1 4 IV
Company Name pp 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:51.`"L C_ 1"") �I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) ft. ft. 1n•
ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SiZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Xi:esidential Water Supply(single) ft, ft, in.
Industrial/Commercial DResidential Water Supply(shared) IS.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: C) ft. (20 ft. )3ef4 jvtie Cil II?5
Monitoring DRecovcry ft. ft.
Injection Well: ft. ft.
Aquifer Recharge I.Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology IOSubsidence Control it. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DUCRiPTi N(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) In Other(explain under#21 Remarks) 0 ft. la ft' IZ e d C) i
4.Date Well(s)Completed:10 "i -2 Well 11)# D ft. 5j 5. R' 5}7 d P-®CI 9
5a.Well Location: SS—ft- ag a ad a e (1-Np1V T Jt e
ft. ft.
Facility/Owner Name Facility iD#(if applicable) ft. ft. r-.e,.-_ ,.-;-, F 'TT,
ft. ft. , ,,.r`.,,1....7 •/ +—I_
i o�a Rea d i tv ri Ci" t� A
Physical Address,City,and Zip ft. ft.
n CT 0 9(, 2024
J1 I ig i X nu L e 21.REMARKS
County Parcel Identification No.(PIN) r. "`
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W ......7 i /6-I - 2
.6.Is(are)the well(s)l y Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the we/l(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or ONo with 15A NCAC 02C.0100 or 15A 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: C (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2(4)100') construction to the following:
10.Static water level below top of casing: S 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: COO (in.) 24b.For Iniectfon Wells: In addition to sending the form to the address in 24a
a above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: J�1 d Zi )1 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) )0 Method of test: 'i(1 h 4 24c.For Water Supply&Injection Wells: In addition to sending the form to
p the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: r 14 Amount: 11 h C2 'Z- completion of well construction to the county health department of the county
where constructed. i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016