GW1--06352_Well Construction - GW1_20241025

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A MO ft. /6/ ft. 3 6/p, ill
(452) fL 45-A ft. A ( t(77rlM
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, IA ft. 6�t'� in. c,t�iZ I
6-i V;
. .y t 4�'� n 16.INNER CASING OR TUBING(gefothermal closed-loop) I
2.Well Construction Permit#:`- t1`' 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.
17.SCREEN
Water Supply Well: . .
FROM TO DIAMETER SLOT SiZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) gRcsidential Water Supply(single) ft. ft. in.
Industrial/Commercial 0 Residential Water Supply(shared) 18.GROUT
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: V ft. .� © ft. L7 -111) e 04 i p 5
Monitoring 0Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge 0Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery [Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology Ell Subsidence Control ft. ft.
Geothermal(Closed Loop) EllTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,sail/reek type,grain size.etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) Co ft. ft. I
4.Date Well(s)Completed: t;/ --"1y C'
-2 7 Well ID# 6 R' 3+O ft- j AN a Re (.,r
5a.Well Location: 30 it' 9'651i. 13 j 0t e Gri-BANG c
I
Facility/Owner Name Facility iD#(if applicable) ft. ft. r t.4 I,a'y ed i..-L=`
ft7 i Oar�cc cr-ilapl�e Cep-I re./ lie fL 0CT fI : znn
Physical Address,City,and Zip
ft. ft. r °�
2l.RF1NiARKS .- .. ;}-�.'���o�':% :.r.::
County Parcel Identification No.(PIN) ^' .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lat/long is sufficient) 22.Certification: r�
N W CeG'". ILI �7
6.Is(are)the well(s) ermanent or Temporary SrgnaWn of Certified Well Contractor Date
By signing this firm,I hereby certitu that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or,No with 15,1 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 cope'of this record has been provided to the well owner.
repair under#21 remarks section or on the buck of*this form.
23.Site diagram or additional well details:
8.For Geoprohe/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 I 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 if-different(example-3 rr 200•and 2d100') construction to the following:
10.Static water level below top of casing: /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: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
r above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: ,I i� iL.i I t 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) 5 Method of test: ;rib 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 7-14 Amount:/ty e2 7__ completion of well construction to the county health department of the county
where constructed. i
I ,
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016