GW1--06138_Well Construction - GW1_20241014

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: =-- --___
1.Well Contractor Information:
Chris King 14.WATER ZONES I i '
Well Contractor l4amc FROM TO DESCRIPTION
2080-A a" 5-7/ ft . O! h l'Irvi
ft. ft.
NC Well Contractor Certification Number
IS.OUTER CASING(for multi-cased wells)OR LINER(if ap livable).
Aqua Drill, inc. FROM TO DIAMETER THICKNESS I MATERIAL
Company Name Q Ct. so R ; in. S fZ r l7(v
/ % 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: (p ,[' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17.SCREEN
A R]CLL1tLLrd1 FROM TO DIAMETER SLOT SIZE THICIOIESS MATERIAL
6 Municipal/Public ft ft. in.
DGeothermal(Heating/Cooling Supply) ,,Residential Water Supply(single) ft ft in .
DIndustriaVCommercial DResidential Water Supply(shared) IS.GROUT
jlIrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 2�� h• (JCJtIii11r� C h�I�'
Monitoring Recovery ft. it.
Injection Well:
Aquifer Recharge
ft. ft.
9 Se OGroundwaterRemediation
5
Aquifer Storageand Recovery
19.SAND/GRAVEL PACK(if applicable)
ry QISa11Irity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStotmwater Drainage tt. ft
Experimental Technology3
DSubsidence Control ft. ft
Geothermal(Closed Loop) QlTracer 20.DRILLING LOG(attach addlttatnl sheets if necessary)
JGeothermal(Heating/Cooling Return) flOther(explain under#21 Remarks) FROM TO DESCRIPTION(cotaw hardaes soil/reektype grain size eta)
� 0 ft. S ft. ?c.4 (.7V/fr /
4.Date Well(s)Completed:9-3 "oc-C?Well ID# _ S- ' 9.5 ft. $i.ini(! I -. c,C
Sa.Well Location: t'5.- ft• 7e'It. d3 1(1 'r. f' t'ii i't'e
Si-C lYNCi .. Pv.6+01 ft. it.
Facility/OwnerName Facility lBS(if applicable) R• t`T•. + i ',I"'2 C.
S \ ,,Si ,_ .. l
IC ry C.�p 4Se v 1`t L(4C,%5nAiUc i i L/pl U�' , C. ft ft ---
Physical Address, r City,andZip' ?�22 ft.. ft OCT Jl `.. 202'4
#61(e ZCy A / 21.REMARKS
CountyParcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Orwell field,one lat/iong is sufficient) 22./CCeJerti��fication
W
N
t ianent or OITempotary Signature of Certified Well Contractor Date
6.Is(are)the well(e) Per
By spring this form,I hereby cei t/I)'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or.4111110 with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
!Phis Is a repair.fill out(moan well construction it formation 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
S.For GeoprobelDPT 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: �/ (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths fd//Jferent(example-3©200'and 2®100) ' construction to the following
10.Static water level below top of casing: U (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing are"r" 1617 Mail Service Center,Raleigh,NC 27699-1617 •
11.Borehole diameter: 6 (in.) 24b.For infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: /2 �E/121 f above,also submit one copy of this,form within 30 days of completion of well
(i.e.auge,rotary,cable,direct push,etc.) construction to the fallowing
Division of Water Resources,Underground Injection Canby!Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 'Method of test: 1(7 0 4' 24c.For Water Supply&Infection 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 11 Amount: completion of well construction to the;county health department of the county
where constructed.
Form GW-I North Carolina Dcpanmeat of Environmental Quality-Division of Water Resources Revised 2-22-2016