GW1-2021-03388_Well Construction - GW1_20210607

i
- �r1nt Form
WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Chris King �'° ��, u 14.WATER ZONES
Well Conductor Name FROM TO DESCRIPTION
2080-A 7 2021 ft. ft. (h
ft. ft
NC Well Contractor Certification Number Vnit
n p[OC�.o ng 15.FROOUTERCM I TOSING forma I MEsT Reps OT CKNESS LINER(if a hMATERIAL
Aqua Drill, Inc. ►p1�®fi�'�ab�R ggcnon O ft. 0 ft. , in. I$ 1 v
Company Name t
�r,n���� I� 16 INNER CASING OR_TUBING cothermal closed-lob
2.Well Construction Permit#: C• FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,Coun)4 State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft.- ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) iMesidential Water Supply(single) ft. ft in.
Industrial/Commercial Residential Water Supply(shared) 8.GROUT
Ini ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: R. ft j e
Monitoring Recovery ft ft.
Injection Well:
ft. ft
Aquifer Recharge Groundwater Remediation
19 SAND/GRAVEL-PACK`if ii'7icible
Aquifer Storage and Recovery [3Salinity 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 Wilitionlii sheets if.necessa
Geothermal eatin Coohn Return Other(explain under#21 Remarks FROM TO DESCRTION color,hardness,9WLImck rain si etc
it ft IP C
lay
4.Date Well(s)Completed Well ID# ft. ft G{ C
5a.Well Location: _ft, ft ry1
ft. ft
Facility/Owner Name Facility ID#(ifapplicable) ft. ft
Iq�O i 1 (n 1.1�' �- ,-i/LArl)S F;e 1 I2) ft. ft.
Physical Address,City,and Zip ft ft
A la
_ 31.REMARKS
County m Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certir, on:
4
} I
N W /
6.Is(are)the well(sPermanent or Temporary
Signature of Certified Well Contractor 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: DYes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 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 remarkr 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: r� (ft) 24a. For All Wells: Submit this)form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2@1001 construction to the following:
10.Static water level below top of casing: 5-0 (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: /� / (� 1Z f I 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) I Method of test: e 24c.For Water SUDDIv&Iniecti`n Wells: In addition to sending the form to
r the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: Z_ completion of well construction t !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