GW1-2021-03387_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD(GW-1) For InternalUse Only.
1.Well Contractor Information:
Chris King :14.
WATEIV'ZONES
Well Contractor Name '
REUt:1 FROM TO DESCRIPTION
ft. e�T'
2080-A
ft. ft
NC Well Contractor Certification Number 7 15.OUTER CASING:(for m I fdti-c ased=welfs),01111NER(if i I rp'linable)::_
Aqua Drill, Inc. processing Unit FROM TO I DIAMETER I THICKNESS MATERIAL
ft.
Company Name 'lllv"­_6WR Ser,'V'On 16.INNER CASING OR ING(geothermal closed-lbop)
2.Well Construction Permit#: FROM TO _ DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Yarlance,etc.) ft. ft. In.
3.Well Use(check well use): ft ft. In.
Wat
er Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT Sin THICKNESS MATERIAL
Agricultural 13 Municipal/Public ft. fL
Geothermal(Heating/Cooling Supply)residential Water Supply(single) ft. It. io
Industrial/Commercial 13Residential Water Supply(shared) I&GROUT
Irrigation FROM TO DIA AL -EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: It. _ ft.- -9
eo 6� (I: -s
3Monitoring [)Recovery ft. ft. I
Injection Well: ft. ft.
3Aquifer Recharge [3Groundwater Remediation
I-
.19.SAND/GRAVEL PACK-(ifs OO]itibli),-...----."..'.7:�l;':..!,--�-���-::.�-'�,k���!���u�?a ,7�
Aquifer Storage and Recovery [)Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology [3Subsidence Control ft. ft.
Geothermal(Closed Loop) [3Tracer 20;DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/C oling Return) r3Other(explain under#21 Remarks) 1 FROM TO DESCRtPT1g)N(color,hardness,wWrock type,grain etc.)
ft-
4.Date Well(s)Completed: Well ID# ft.
5a.Well Location:
a o�� r-�z-�►�� w�� � ft
Facility/Owner Name Facility ID#(if applicable) ft. ft
ft. ft.
Ph V1 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 lattlong is sufficient) 22.Certificatio
N W
6.Is(are)the well rmanent or 13Temporary Sigi,4.;..fCe Ai=idWelll 1" Date
By signing this form I hereby certify that the well(s)was(were)constructed in accordance
1.Is this a repair to an existing well: ®Yes or 00 with 15A 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#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
S.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 of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 24a. For All Wells: Submit this',form within 30 days of completion of well
For multiple wells fist all depths ifalifferent(example-3@2Q0'and 2@100) construction to the following-.
10.Static water level below top of casing: (ft.) Division of Water Resou rces,Information Processing Unit,
lfwater level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:
(in 74b.For Infection 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: 1636 Mail Service C6nter,Raleigh,NC 27699-1636
1
13a.Yield(gpm) Method of test:S,I,), 24c.For Water Supply&Infection Weflk' 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 t 9
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