GW1-2021-00341_Well Construction - GW1_20210127

Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: = 4
Chris King 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
tIL
2080-A [a�� 2 t
k! ft. _l D ft.
NC Well Contractor Certification Number 15.OUTER CASING for mull Zsed wells OR LiNER if a livable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 163ft. ft 6/ s in V t
Company Name t
0 -0 1 `e-4 yx �l l' _Q 16.INNER CASING OR TUBING eothermal HICKNES
2.Well Construction Permit#: H � FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. fa in.
17.SCREEN
Water Supply Well:
pp y FROM TO DIAMETER• SLOT SIZE THICKNESS MATERIAL.
Agricultural gMunicipal/Public Q IL ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft in:
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
lrrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: It. IL eto-} JC,�
:)Monitoring DRecovery ft. ft.
Injection Well:
ft. It.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
U Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ©IStormwater Drainage ft. ft.
Experimental Technology [)Subsidence Control ft. It.
Geothermal(Closed Loop) ®ITracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRrntfON rotor,hardness,soiVrock a in size etc
r� ft s ft.
4.Date Well(s)Completed: J . , / Well ID# ft ft 4/5--2 i 1
5a.Well Location: ft. ft j
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
C 214 D k ft. ft.
Physical Address, and Z ft. FL
21.REMARK$
Cy
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minute's/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifi lion'
N W
6.Is(are)the well(s) Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was'(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or �10 with 15A 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 copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
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 NIJM13ER of wells construction details. You may also attach additional pages if necessary.
drilled: c� `�-a {SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Q �� !d (tC)�124a. For All Wells: Submit this form within 30 days of completion of well
For mu/tiple we/!s list all depths if different(example-3@200'and 2@100') construction to the following:
10.Stat*i ter 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: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
1 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: j �Z C� 1 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) �(J V Method of test: ✓ 24c.For Water SuDDIy&Infection Wells: In addition to sending the form to
�j -7 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: D Ci completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016