GW1-2021-02638_Well Construction - GW1_20210620

Print Form
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
ft. ft.
NC Well Contractor Certification Number���fff / ^ 15.OUTER CASING for r Mf-cased wells OR LINER if a 0cable
Aqua Drill, Inc. ��" J� J �J�o�7/ FROM TO DIAMETER THICKNESS MATERIAL
///��� iC < V s ft. ft an. - -21
Company Name 16.INNER CASING OR TUBING(peothermal dosed oo l✓
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,Countv,State, Hance,etc.) ft. ft. In•
3.Well Use(check well use): k. k.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) sidential Water Supply(single) k. ft. in.
Industrial/Commercial Residential Water Supply(shared) 1R GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. fL a `
Monitoring Recovery �r
Injection Well: ft. ft.
Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM To D' CRIP PION co r,hardness,solVnwk tyM grain size,etc.)
4.Date Well(s)Completed Well ID# ft. O ft.
5a.Well Location:
COLL, hz/1 ft. ft.
Facili wner Name Facility►D#(if applicable) ft. ft.
vs/ Ea
/.•x ft. ft.
Phys al ddres�City,and Zip / 1 L ft. ft
1 n 21.REMARKS
County Parcel Identification No.(PIN) Illl
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one ladlong is sufficient) 22.Cc ' c on:
N W
6.Is(are)the wells) ermanent or 13Temporary ature o 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)!fvo with ISA 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 cop)'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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surfacer- (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@20/0''a�nd 2@I00� construction to the following:
10.Static water level below top of casing: �LJ (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 Iniection Wells: In addition to sending the form to the address in 24a
` above,also submit one copy of this form within 30 days of completion of well
12.Well construction method - 14 1!� `'��1 ` construction to the following:
(i.e.auger,rotary,cable,direct push,e )
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ' Method of test: 10hir 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016