GW1--06810_Well Construction - GW1_20241114

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
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Well Contractor Name FR/OOM TO DESCRIIPPTTIO�N
2080-A 1 W O f't. 1 G 9 ft. I V f! 1 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 I MATERIAL
Ft. •'2 ft. e �. in. 5 �Z
Company Name ✓ 0 D , i ✓,c
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:(.)2 I -0 I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits'Le.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
Agricultural D Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
Industrial/Commercial 0Residential Water Supply(shared) 18.GROUT
Irrigation FROM�l TO MATERIAL EMPLACEMENT METHOD&AMOUNT
V
Non-Water Supply Well: ft. 0 ft. 13e/140N ik C 61 1)S
Monitoring DRccovcry ft. ft.
Injection Well:
-
ft. ft.
Aquifer Recharge DGroundwater Remediation
Aquifer Storage and Recovery Et Salinity Barrier 19.SAND/GRAVEL PACK(if applicable)
kJ tY FROM TO MATERIAL EMPLACEMENT METHOD _
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soittroek type,Grain Ate.etc.)
4
0 ft. 3 ft. ) cd (Any
4.Date Well(s)Completed:! '' -,.. Well ID# 1 ft. I,5" ft.
514/Ud Re C.I .
5a.Well Location: '5 ft. "C 5�ft. M r7 d Je- eiz u+4 e
t' t� ft. ft.
Fis 'eg
Facility/Owner Name Facility
ID#(if applicable) ft. ft.•
`� p'"'r' i' t,
j 3 1�7� �1I�S�Grg�f'�IJL "- ft. ft. NUV 1L [UL`t
Physical Address.City,and Zip ft. ft.
0 12.11 11/419 21.REMARKS - N _ ,
County Parcel Identification No.(PiN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W C��� ��
s II-6-.4 Lf
6.Is(are)the well(s Permanent or IJTemporary Signature of Certified Well Contra Date
By signing Ibis form,I hereby cerrih&that the.sells)was(were)constructed in accordance
7.Is this a repair to an existing well: IJYes or ATo with I5A NCAC 02C.0100 or 15,4 NCAC 02C.0200 Well Construct/nn Standards and that a
Ifthis is a repair,fill out known well construction information and explain the stature of the copy of this record has been presided to the well owner.
repair under#21 remarks section or on the back of this farm.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
FL For Geoprobe/DPT 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: ''''O S at-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths 11-different(example-3@200'and 2 r)100) construction to the following:
10.Static water level below top of casing: d (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
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: / D.1Z Iz.i 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
13a.Yield(gpm) I Method of test: 5 lei)1-e- 24c.For Water Supply&iniection Wells: In addition to sending the form to
T / the addresses) above, also subtriit one copy of this form within 30 days of
13b.Disinfection type: 14/ � Amount:/ ffl C) '�- completion of well construction tol the county health department of the county
where constructed.
P
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016