GW1--05987_Well Construction - GW1_20241009

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: •
Chris King 14.WATERZONES ' - -
FROM TO DESCRIPTION
Well Contractor Name 370t. 37/ ft. 3 6.1 i !i
2080-A �7ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable),
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS. MATER,eI�A)L, �+
to ft. /„D2. ft t,®� in. )Ig �-il 1f�
Company Name `
57 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: e I. ; 9 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County.Slate.Variance.etc.) ft. ft. in.
3.Well Use(check well use): R. ft. in. .
Water Supply 1 Well: 17.SCREEN
FROM !TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipal/Public It. I it. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft, it. DIAMETER
Industrial/Commercial I�Residential Water Supply(shared) 18.GROUT _
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
)Non-Water Supply Well: 0 ' ft. I,go ft. gej ,g� � 1 es
Monitoring °Recovery ft. I/X ft.
Injection Well:
ft. I ft.
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery °Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
jAquifer Test 0Stormwater Drainage ft. I ft.
jExperimental Technology °°Subsidence Control ft.! ft. • '
jGeothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM 1 TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Retturn) Other(explain under#21 Remarks) ® ft 112 ft- e r C i y
4.Date Well(s)Completed AC 2 9 Well ID# f a f•13.-R. 50Aptici gjcf(
5a.Well Location: 3 S-ft,i yQ c ft, i•3 i ti e /.�}U A a
ft.I ft. I �s+'il:F.t`"'a.' ,
_ �g. 1Ta;j`
Facility/Owner Name Facility ILA(if applicable) ft I ft. ;°"° V t...1,...e
1
�� c ft.. ft. Ut 10.v 2024
1 �1O3 ��1t •
Physical Address,City,and Zip ft.I f' l^`' ,,-, _ „
,/A i C,C 21.REMARKS
County Parcel Identification No.(PIN) I y ^'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lot/long is sufficient) 22.Certific don: ,
N W24 .... ,24 _g `
6.Is(are)the wells ermanent or Temporary signature of Cat cd well Contractor. Date
By signing this form.I hereby certify that the well(s)was(ivere)constructed in accordance
7.Is this a repair to an existing well: ®Yes 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 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 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: LI 0 (ft•) 24a. For�I Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2Q100') construction 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: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
1 above,alsol submit one copy of this form within 30 days of completion of well
12.Well construction method: 691)z IGl 1 1 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division I of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test: 5.i U li+ 24c.For Water Supply&Injection Wells: In addition to sending the form to
ii 7 DD 1 the address(es) above, also submit.one copy of this form within 30 days of
13b.Disinfection type:07/ Amount: I 0 completion)of well construction to the county health department of the county
where constructed.
•
Fours GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-20(6