GW1--06210_Well Construction - GW1_20241021

WELL CONSTRUCTION RECORD(GW-1) • For Internal Use Only: L_____7.___ ,___ _ _ _
1.Well Contractor Information:
Chris King
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A 391 rt. . 3 ft. .3 6., fir r"t
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-eased wells)OR LiNER(If ap licable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 170 ft. IC /, in. 51P/Z.,.(� I i I)`1.
p Y
r} 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:0 D,ci -000Q IcS 7 6 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
FROM TO
ft.
ft.
DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural Municipal/Public ft in.
in.
Geothermal(Heating/Cooling Supply) 1•esidential Water Supply(single)
H.
Industrial/Commercial Water Supply(shared)
IS.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. ,�Q ft. � '�. ry i4C C �75
MonitoringRecovery fL �( ft.
Injection Well:
Aquifer Recharge ft. ft,
qDGroundwater Remediation
Aquifer Storage and Recovery19.SAND/GRAVEL PACK(if applicable)
SalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DIStormwater Drainage ft. ft.
Experimental Technology (Subsidence Control ft. ft.
Geothermal(Closed Loop) 1:11 Tracer
20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) IlOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soi0rock ripe grain size,etc.)
FROM _ ft. A
4.Date Well(s)Completed:/0 1/ ".2 f-(Well ID# � ft. ( 57 ft. 5 q N dci! cc
5a.Well Location: Cos-- ft. c/d y.ft. 131 ae 6 i2AIN i I t-
Cli\1h t rsJ f/c�1 n Z6 c- ft. ft. -�
Facility/Owner Name Facility iD#(if applicable) ft. f6 6 �. ..-, •e_.,+e.:._- -.z._,
2601 5 ,(.„, y r R ill 50 hilt yV.0 ft. ft. OC.T 9, 1 20Z4
Physical Address,City,and'Zip It. ft.
g J 104
ill,-Q 1 p 4 21.REMARKS 1 t
County I iJ:Vk.��vv
Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 22.Certification:
N W .4„..:„D'
6.Is(are)the well(si,Permanent or DTem ora Signature of Wcl Contractor /6 ��- t
l p ry Date
B.t•signing this form,I hereby ce,7ify that the well(s)was(were)constructed in accordance
7.1s this a repair to an existing well: ]Yes or lallo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Consbvction Standards and that a
!f Uhis 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#2!remarks.section or on the hack r f this fr,rm.
23.Site diagram or additional well details:
A.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: (.j J (ft.) 24a. For MI Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths if dperenl(example-3 rr 100'and 1Q100')
10.Static water level below top of casing: (o
U construction to the following:
iIfujater level is above casing.use••+ (ft) Division of Water Resources,Information Processing Unit,
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
12.Well construction method: 1i i"�. d l�i(� above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636 ,
13a.Yield(gpm) Method of test: S i cjr 114 24c.For Water Supply&Injection Wells: In addition to setiding the form to
/ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: /�/ I � Amount: 1 e O 2_ completion of well construction toj the county health department of the county
where constructed.
f
Form GW-1 North Carolina Department of Environmental Quali
ty-Division of Water Resources Revised 2-22-2016