GW1--06721_Well Construction - GW1_20241108

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I
Chris King 14.WATER ZONES
FROM TO DESCRIPTION
• Well Contractor Name
2080-A el ft. �rZ ft. ;'(�-sP ii°'Q
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/p THICK S MATERIAL. s
ft. E� '�' ft 6%sgin. ),1 6- 1)1i
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: �C:.) W('�-�rt/ d�-q FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constriction permits(i.e.UJC.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
DAgricultural OMunicipal/Public ft. ft. in.
DGcothcrmal(Hcating/Cooling Supply) gResidential Water Supply(single) ft. ft. in:
0Indus(ria1/Commercial DResidential Water Supply(shared) 1&GROUT .. -
I 1 irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 2 G`1 ft. r e,.,u I-,v;�e e 'j pS
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
• DAquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
QlAquifer Test DStormwater Drainage ft. ft.
DExpetimental Technology Subsidence Control ft. ft.
DGeothermal(Closed Loop) ITracer 20.DRILLING LOG(attach additional sheets if necessary) _
FROM TO DESCRIPTION(color,hardness.snit/rock type,grain size.etc.)
OGeothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) day ft. 6 ft. 56 b' A
•
4.Date Well(s)Completed: I '30 .7 9 Well ID# 6 ft- 35--ft- 5 AN d JZ G C 4'
5a.Well Location: 3.5-R. . )S'-rj ft. )3 i1 U e a piry °'_)C.
ft. ft.
Facility/Owner Name Facility iOU(if applicable) ft. ft. {^^,�. •'1,r 3 ill':..1
1 ft. ft. lot) A 4-) Ann.
�'��`9 - �b.�c; G ft. ft. �'-,, to U 4.116.1
Physical Address.City,and Zip
{fit 21.REMARKS '
County R+6 Parcel Identification No.(PIN) C °{`i' `a '`
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one fat/long is sufficient) 22.Certifies'on:
N W -'
6.Is(are)the well(s)!5:'ermanent or OTemporary Signature of Ccrtific Well Contrecmr Date
- By signing this form,1 hereby certifi'that the well(s)was(were)constructed in accordance '
7.Is this a repair to an existing well: IYes or 'No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Consiuction 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 under#2!remarks section or on the back of this firm.
23.Site diagram or additional well details:
8.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: f (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi©et-ent(example-3@200'and 2@100'), construction to the following: 1
10.Static water level below top of casing: ld (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 Infection Wells: in addition to sending the form to the address in 24a
d above,also submit one copy of this'fotm within 30 days of completion of well
12.Well construction method: Ill I C.11, 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) . 0 Method of test: 1 C; IA• 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: ki r,1 Amount: /6 6'L completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016