GW1-2021-01099_Well Construction - GW1_20210215

tint.Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
d
Chris King 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
2080-A aft oGr'I Cft o S r-A
ft. I ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER'if a licsble
Aqua Drill, Inc. FROM TO DIAMETER I THICKNESS ]yjATERIAr.
1 ft ft / in c
Company Name C/ l t
16♦:INNER'CASING OR'TUBUVG_ eothermsl;dosed-too `
2.Well Construction Permit#:�1 —I o FROM TO DIAMETER THICKNESS MATERL&L
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): & fr' in,
17.SCREEN
Water Supply PP Y Well: FROM TO DIAMETER v SLOT SIZE THICKNESS MATE RLkL
Agricultural DMunicipal/Public 0 ft & in.
Geothermal(Heating/Cooling Supply) 6Wesidential Water Supply(single) ft. ft. in
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft Q fL !y7 G
'Monitoring ORecovery ft. ft
Injection Well: ft ft.
Aquifer Recharge E3Groundwater Remediation
19.SAND/GRAVEL PACK if.a ticable
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test O Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
il
cessary)1
Geothermal(Heating/Cooling Return) []Tracer
(explain under#21 Remarks) FROM TO DESCRIPT ON(coif,hardne
ft ft ON color,hardness,soiVrock e, is size,eta)
Geothermal Closed Loop) Tracer 20.DRILLING LOG attach'additron
4.Date Well(s)Completed:,/ na Well ID# ft 0 fL s IC5a.Well Location: 1' 6- U - w
C�QA.-�t'C Yl 'Gl'E7�.(✓.��W � ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft ft
ate)l`f Eig- - 1 ( ft ft
Physical Address,City,and Zip CO 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/Iong is sufficient) 22.Certifi lion
N W
6.Is(are)the well(s);Permanent or OTemporary Signature of Certified Well Contractory Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or AM�4o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
1f 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 NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: y SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 24 .,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 2@I00') {fp :A .�+ �66nstruction to the following:
10.Static water level below top of casing: *sy- (ft.)t�Ot1` Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" f 1 b 1� L 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) ` ,-2oi Fdr Infection Wells: In addition to sending the form to the address in 24a
i 1 +,r'' ' above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 12 11Z i.'<'".;n r..
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) <O Method of test: 24c.For Water Supply&Infection 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