GW1-2021-03219_Well Construction - GW1_20210624

;P.rint 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
k, ft
NC Well Contractor Certification Number 15.OUTER CASING focmWti-cased wells OR LINER if applicable)
Aqua Drill, Inc. FRo To DIAI�TER THICKNESS MATERIAL
Company Name ft. 57 It w in, s 191z.2/ V
'16.INNER CASING OR TUBING eother►nsi dosed-loop)
2.Well Construction Permit#: 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.
Water Supply Well: 17.SCREEN x
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural MunicipaL/Public k. M in.,
Geothermal(Heating/Cooling Supply) Jokesidential Water Supply(single) k. ft
Industrial/Commercial Residential Water Supply(shared) i8.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: k. 0 fL )Jyt�
Monitoring Recovery ft. ft "
Injection Well: k t f
Aquifer Recharge Groundwater Remediation 19:SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft ft
Experimental Technology Subsidence Control ft It.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/CoolingReturn Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness soiVrock in s' etc.)
^� k. ft
4.Date Well(s)Completed:'(- �( 1 Well ID# ft. S ft S y')a Y"
5a.Well Location: k.
���"e c, ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. It.
V o 1 Lk Q,/3 ¢;rvvko, n c-
ft. ft
Physical Address,City,and Zip It. It.
21.REMARKS
InfarM3 lon
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.Certification:
6.Is(are)the well(s) Permanent or OTemporary Si re of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)const=ted in accordance
7.Is this a repair to an existing well: ®Yes or 6o with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
Ifthis 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: 165
(It-) 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:
10.Static water level below top of casing: <D (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 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: 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: /1 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �`� Method of test: 5l /j 1 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 completion of well construction to4the county health department of the county
where constructed. M
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016