GW1-2021-03460_Well Construction - GW1_20210607

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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 pft. fL I t F.
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING:formulti cased wells':OR LINER:'if
"ticable
Aqua Drill, Inc. FROM To DIAMETER THICKNESS MATRRtet.
® ft. °J ft I y m. V G°
Company Name
16.INNER;CASING:ORTUBING' a"othermald6sed400
2.Well Construction Permit# I 'd ��UL)I-� ( �C{ 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
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural MunicipaVPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. fa in.
Industrial/Commercial Residential Water Supply(shared) 1ii GROUT -
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. Q ft Q� JC
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
�I9i'SAND'lGRAVEL`PAGKi If;a'""`lic"able ...
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control [t. It.
Geothermal(Closed Loop) Tracer 20r DRILLING.LOG atNeli addltiooal sheets;if:uecessa ' `
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,soi0rock type,grain size,etc.
l ft. tt (: y
4.Date Well(s)Completed.•S- 9 -J I Well ID# Q ft. ft. /� d
Sa.Well Location: ft S-" (O C
ft. It.
Facility/Owner Name Facility ID#(if applicable) ft. ft. p
7 ft. ft. i .
Physical Address,City,and Zip ft
ft ft
,r(1r )d FA 1Z V 21.REMARKS '
County Parcel Identification No.(PIN) U"11
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: rnvvp,jgdon
(if well field,one lat/long is sufficient) 22.Ce ti
e
6.Is(are)the wells) Permanent or Temporary rgnature of Certified Well tractor e
tt�T 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: ®Yes or EIo with ISA NCAC 02C.0100 or 15A NCAC 02C.0100 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 thisform. 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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: ff G SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 n 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2Qa 1001 construction to the following:
10.Static water level below top of casing: L/ (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 Infection Wells: In addition to sending the form to the address in 24a
7 \ above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: t (z de 1 11 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) Method of test: c5 t Q�.� 24c.For Water Supply At Injection 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: 6 Z completion of well construction to the county health department of the county
where constructed. t
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016