GW1-2021-01108_Well Construction - GW1_20210322

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER TONES
FROM m TOJ DESCRIPTION
Well Cuntractor Nae -joft. O b. �� / t m
2080-A v
I, R
NC Well Contractor Certification Number 15.OUTER CASING for meld-oaN wens OR LINER Ff• bk
Aqua Drill, Inc. FROM TD ORmEIER THICKNESS MATERIAL
U ft. �[ fG 6! rt / 1 U
Company Name `l J Y t
336 SG 3 M MfL CASING OR TUBMG my dAC Non
2.Well Construction Permit#: FROM To DRmerER THICKNEss MArex1AI.
L,«ell apphcable well nrnvrunmn permu,or,Uhl Onion,.Pare,Ibnance,em.l h ft t
3.W ell C'se(check well use): ft. ft. L r
n.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricuhural Municipal/Public 0 ft H. in.
NGeothermal(Heating/Cooling Supply) EfR.sjdential Water Supply(single) ft fttn.
Industrial/Commercial OResidential Water Supply(shared) I&GROUT
itirgation mom TO MATERIAL EMPLACEMENT METHOD&AMOUNT
t
Non-Water Supply Well: ft �C• R
Monitonng 011ccovery h. h.
Injection Well:
IL It.
Aquifer Recharge []Groundwater Remediation 19.SANWGRAVEL PACK ff• ble
Aquifer Storage and Recovery Salinity Banner mom TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage fL ft.
Experimental I echnology []Subsidence Control fL ft
]Geothermal(Closed Loop) []Tracer 20.DRILLING LOG fattech additional shrxb Bore
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) EROm TO DESCRU?"OONreler,hrNenr,wil/rark mrve,nr.
ft fL e (214
L
4.Date Well(s)Completed: I - Well ID# fL (G� fL rj_ail iod Z�r C
5a.Well Location:: OSTt. o f s 1 c
ft.I�O�SV1+#F1 l�I h7 � ft O It.
Y
FacilitrOwner Name —r Facility IDa l ifapplicable) ft R
t2Z 1jnne41��1 F fL
RP{hh�a cal Address,City,and Zip rt(.r— it 705'1 ft h'
oe- Ar,J un 6 0q 5— 1 21.REMARKS
M
Counts Parcel ldrntiication N..(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,
(if well field,one lavlongissutie,e.,) 22.Certification: 3l.f N' W ( - J _ e
6.Is(are)the well(s)6ma ernent or ®Temporary Signature ofccrtifie. Well Contractor Dare
/% Hr ibex fnm. l hereby oe 1yi 1ha1 the xe/l/,ry wos(wet)rvnrtrvaed m annrdonce
7.Is this a repair to an existing well: []Yes orArNo a uh 15A.vCAC 02( 0100 or I5A M A('02('.02W Well Cu.1.oun Sui dordr and Ihat a
/6(do,is a repaq fill eta known well canslruction information and a alatn the nature effhe copy of Zhu record has been provided to the well owner.
repair under d2l remarks section car can the back rfrhis jnrm.
23.Site diagram or additional well debits:
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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
dolled: Z St BMITTAL INSTRUCTIONS
9.Total well depth below land surface: �J (R) 24a. For All Wells: Submit this form within 30 days of completion of well
R,r mulnple wellslist a11depth..ndperent(example-3@200'and24u)/00') construction to the following'.
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
ljwater level a above costa,,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
s above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: A ; /Z uZ v, 1 construction to the following.
n e_auger,rotary,cable,direct push,ea_)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) SO Method of lest: 24c. For Water Supply& Infection Wells: In addition to sending the form to
I / ') the address(es) above, also submit one copy of this forth within 30 days of
!13b.Disinfection type: �Y T N Amount: ,2 y 01 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Envimnmemal Quality-Division of Water Resources Revised 2-22-2016