GW1-2021-03389_Well Construction - GW1_20210607

rant Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King gECEIV r— 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A J U N X ? 2021 A70 it' 9& 1 0 44,
ft. ft.
NC Well Contractor Certification Number recessing Unit
Aqua Drill, Inc. �fl#affr;atlon� IS:OUTER CASING formultf�ased wells)OR LINER;ifa ticable
A '
q DWIR Secton FROM I TO DIAMETER THICKNESS I MATERIAL,
ft. 14o.3 ft 1 6 in. Ct Y A J
Company Name r 3
'16t INNER CASING OR TUBING eothermal cloaca-loo ^ ;
2.Well Construction Permit#: 6 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) h• ft. In.
i
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. rn
Industrial/Commercial `Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: R ft I
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation _
19�'SAND1G1tAVEL•PACK�tis"'licetile � ->� ��:�"?a?'+'�`?'
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control It. R
Geothermal(Closed Loop) Tracer X DRILLING LOG attach additionil sheets if:necessary)
Geothermal eatin Coohn Return Other(explain under#21 Remarks) FROMI TO DESCRIPTION color,hardness,sailtruck rain si etc.)
® th to %
4.Date Well(s)Completed:,5- 7 J Well ID# Q ft. 16 fL 5 c( O
5a.Well Location: .7 6 It. ZC� t.
1 14' ) ft. ft.
Facility/Owner Name Facility 1D#(if applicable) ft. ft.
5/0 GI 118b.b e- ft. ft.
Physi Address,City,and Zip k R
2L REMARKS
County,? Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22.Certification:
N W
6.Is(are)the well(s) Permanent or E3Temporary Si re ofCertifie Well ntractor , Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or afNo with 15A NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under#11 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: Q SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: V (ff) 24a. For All Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@2000'/'aa�nd 1@1001 construction to the following:
10.Static water level below top of casing: V (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: CO (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: I /Z 1 construction to the following:
(Le.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) Q 0 Method of test: 5 I 24c.For Water SUDDIY&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: I 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 4 Revised 2-22-2016
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