GW1-2021-00252_Well Construction - GW1_20210125

—WELLUUINN1KUI-11V1N KLI-UKU IliW-11 rorInternaluseunty:
1.Well Contractor Information:
Chris King 14.WATER TONES
PROM TO DESCRRITON
Well Contractor Name
2080-A � ft ft
Ogt` 198 fL
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if a icaMe
Aqua Drill, Inc. FROM TO I DIAMETER I THICKNESS L MATERIAL
Q it. 110 A in.
Company Name 16.INNER CASING OR TUBING thermal Nosed-loo
2.Well Construction Permit#: 11/Iq� l� `'I PROM TO DIAMETER TIIICKNE55 MATERIAL
List all applicable well conslruGion permits(le.U1C,Counly,State,Variance.etc.) ft. ft. in.
3.Well Use(cheek well use): ft. I in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLAT SIZE THICKNESS MATERIAL
Agricultural OMunicipaliPublic 0 ft ft. ia.
Geothermal(Heating/Cooling Supply) ,Rcsidential Water Supply(single) it, D, in.
Industrial./Commercial QResidential Water Supply(shared) Ia GROUr
Irrigation FROM TO MATERIAL EMPLACEMENTMLTHOD&AMOUNT
Non-Water Supply Well: R• R'
Monitoring Recovery ft It.
Injection Well: ft ft
Aquifer Recharge Groundwater Remediation
19.SANDIGRAVEL PACK iFa liable
Aquifer Storage and Recovery ❑SalmRy Banner PROM TO MATEHI\I. EMPLACEMENT METHOD
Aquifer Test []Stonnwater Drainage ft. ft.
Experimental Technology QSubsidence Control ft. ft.
Geothermal(Closed Loop) ®lYacer 20.DRILLING LOG attach additional sheers if necessary)
Geothermal(Heating/CoolingRealm) Othm(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardoev,sai/mck it sire.err.
�7 40 ft ft G 0
!4.Date Well(s)Completed- '.2 ) Well ID# R' R• Ne90ceI M Ua
5a.Well Location: JlYk I q6 ft O G
�s
R O 1 C
Facility/Owner Name Facility ID#(ifapplicable) 2or
3�3�1 '8 4;rics ►Zc� rzlzr�s✓II1 r ft
Physics]Ad&ess,City,=it a
ro25ya O 21.REMARKS
Com��� Parcel Identification No.(PM)
t araZQ - 6S
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IatAong is sufficient) 22.Certifies' n:
N W
6.loam)the wells) rmanent or QTemporary Signature of Certified Well Contractor Date
((((((������ By signing this form,/hereby certify that the wells)was(were)cat stnicred in accordance
7.Is this a repair to an existing well: Yes or QNo wah 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Well Consoca.Standards and that a
lfdds is a repair,fill out known well cwhuction information am1 ei plain the nature of the copy ofthis record has been provided to the well owner,
repair order 121 remarks section or an the back ofthis form.
23.Site diagram or additional well details:
S.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: (fL) 24a..For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd$erent(esample-3Va100'ad1®l00') construction to the following:
10.Static water level below top of rasing: 1 -0 0-, (ft.) q�rL` Division of Water Resources,Information Processing Unit,
lfwnter level u above caring.use"- N .w.\\ Y z 1, ',4617 Mail Service Center,Raltigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
�f �7 abiwcs` lso submit one copy of this farm within 30 days of completion of well
12.Well construction method: 1 ) 4- 1 t1 1 I cpns[mction to the following:
(i.e.auger,rotary,cable,direct push,etc.) \., ,..
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY
�WL ES ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)1 ) Method of test: the For Water above,
ls Isubmit Wells: In addition to sending the form to
the addresses) above, also submit one copy of this foul within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where cons acted.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016