GW1--06039_Well Construction - GW1_20241011

•
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: L____T
I.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A 70 ft. 7/ ft. AO ' 6.( P 1;>'
ft. 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 MATERIAL
Company Name 0 ft. /'/ it. '/�/ in- 5)jitZ/ I pi v. G
III`O 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.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 Municipal/Public ft. B. in.
Geothermal(Heating/Cooling Supply) i Residential Water Supply(single) ft, ft. in.
Industrial/Commercial (*Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 0 ft. i3 'g 61_--e - 5 .,
Monitoring {{��{{Rccov ® �' 'e� 6 a VI t ., c-
p.p ery ft. ft.
Injection Well:
ft. rt.
Aquifer Recharge IDGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable) _
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) EpTracer - -
20.DRILLING.LOG(attach additianalsheets dneeessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rack t�pc Brain size,ere.)
u ® ft. 6 ft. SO Q /
4.Date Well(s)Completed:® - d -MWell ID# 6 ft• 5: ft. 5)110d RG Cie
5a.Well Location: SS". jigft. MO e (re.Pl jv44e
gr)t ir-5 . ft. fL7pen,
'Owner Name g erg, i ) Facility ID#(if applicable) A ft. ft. I..-T•;< t . •
'7l 2 g 0 d ie✓►3 7 h f9 e N e 1u;t4i 5 i len, eil y ft. ft. r OCT
-I,�_.. � ', l
/Physical Address,® City,and Zip ft ft. 0 C I •g i [(�Z[�
` 1 aq 4-IN l 21.REMARKS
.. ,� '- ;.es fir^.
County Parcel Identification No.(PIN) [?:'i;`,-t t;`:�;::
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certif ation:
0-q --2 (-/
6.Is(are)the wells) ermanent or Tem ora Signature of Certified Well Contractor l6 Date
P ry
By.signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or DNo with 15.4 NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
lfthis 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 ofthis farm
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-l.is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
1 1� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(fd(firbrent(example-33 rr 200'and 2@100') construction to the following:
10.Static water level below top of casing: 60 (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
di e p above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1 I 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
I
13a.Yield(gpm) A 0 Method of test:cS q)1 4 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: 4 7-I) Amount: I(e3 0 .. completion of well construction tol the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources , Revised 2-22-2016