GW1-2021-03064_Well Construction - GW1_20210624

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
z -�. � L
2080-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING. for mtilti-cased we
UR•LINER f;a livable
Aqua Drill, Inc. FROM To DIAMETER THICKNESS MATERIAL
fL r✓/ fL �li iR. n /v
Company Name ?S q© I&INNER CASING OR'T[JBING eothermal closed466
2.Well Construction Permit#: 6�}� 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.
Water Supply Well: FROCEN TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipal/Public ft. ft.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared) 1S.'GROUT
Irrl ation FROM TO MATERIAL: EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. It.
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge 13Groundwater Remediation
;a9.SAND/GRAVEL PACK if a' livable
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test ®IStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20 DRILLING1 attacti ad'ditiohel sheets ifnecesss
Geothermal (Heating/Cooling Return) . Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,so,111.1c type,.ram size,eta
ft. ft.
4.Date Wells)Completed: Well 1D# ft' w-ft. O CK
5a.Well Location: ` T 76 C ft. J fi -v Z
Facility/Owner Name Facility ID#(if applicable) ft' ft'
6 !". l 114 L6, ft. ft.�
Physical Address,/City,and Zip ft' ft 24 N 2U r-4 t I:1`z 214REMARK
County Parcel Identification No.(PIN) InforMation Processing
nl
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
�,1 N W
6.Is(are)the well(s)IhCUPermanent or Temporary Mg—nature of Certified w Contractor Date
0�' `� 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: [3Yes or tI No with 1 SA NCAC 02C.0100 or 1 SA 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 NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: / < SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: t0 J' (ft) 24a. For All Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:0'
10.Static water level below top of casing: `� ® (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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
t tt above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: ) diz I J 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) 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:Z d b Z. completion of well construction toI 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