GW1-2021-01147_Well Construction - GW1_20210215

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A 3"L It- O 6,t R rn
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if applicable)
Aqua Drill, Inc. FROM To DIAMETER THICKNESS MATERUL
ft ft in C
Company Name / t
� �.`u '16 INNER CASING OR TUBING eothermaf;closed-loo
2.Well Construction Permit#:^�LJ I O FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER. SLOT SIZE THICKNESS MATERIAL
Agricultural C]MunicipaVPublic 0 ft. fL in.
Geothermal(Heating/Cooling Supply) dwesidential Water Supply(single) ft. ft. in•'
Industrial/Commercial 13Residential Water Supply(shared) 18:GROUT
_73IIrI atlon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft• D ft.
Monitoring Recovery ft. ft.
Injection Well: ft ft
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVELTACK If a 'Gciible
Aquifer Storage and Recovery EISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20 DRILLING LOG attach additional sheets if necessary)
i Geothermal(Heating/Cooling Return) i�O/ther(explain under#21 Remarks) ft. ft.
FROM TO DESCRIPTION color,hardness,soilimck e, in size,etc
4.Date Well(s)Completed: / 3 (/ Well ID# f 6 FL S K
5a.Well Location: 6 ft. U 6- vu 1
��•xA Kul 'G3'�7LY1.1�_� �� ft. ft.
Facility/Owner Name {� Facility ID#(if applicable) ft. ft.
ate)I U rq �Gi.51 I = & ft.
Physical Address',City,and Zip ft. ft.
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certiri lion:
N W
6.Is(are)the well(s)lPermanent or Temporary Signature of Certified Well Contractorl 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 iffNo with I5A 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 921 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 I GW-I is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft), ,!4a.'For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 1@100')
66nstruction to the following:
10.Static water level below top of casing: `+,�=' (ft) Oq` Division of Water Resoui-ces,Information Processing Unit,
If water level is above casing,use"+" 1 1• \ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 1 ,.24b Fbr Iniection Wells: In addition to sending the form to the address in 24a
'` '�� ` � a ';,i'''' above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1 7 l 1 1 ;' construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) '
I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) O Method of test: 24c.For Water Supply&Iniection 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: Amount: 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