GW1-2021-05455_Well Construction - GW1_20210607

` Pr'nf 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
f �`
ft. ft.
1 :302080-A
ft. ft. '
NC Well Contractor Certification Number 15.OUTER CASING(for muld-cased:wens UR LINER'if a livable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MA
ft. ft. in. l J
Company Name 1 0 V
1 _0 ' �����-Cow,-,
�/ "16 INNER CASING OR Ti1B AM eothermlal oo" s <.
2.Well Construction Permit#: r 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): fL fL in.
Water Supply Well: FROMCREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 1IMunicipal/Public ft. M io
Geothermal(Heating/Cooting Supply) Residential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
lrri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: R' 0 IL ems 2uc (C
Monitoring Recovery ft. ft.
Injection Well:
ft. fL
Aquifer Recharge Groundwater Remediation
19.-SAND/GRAVEL PACK§If.a lleable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD i
Aquifer Test [3Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILL INGLOG attach,addidoiM iiheetsaf.necessi
Geothermal eatin Conlin Return Other a lain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiLtrock m s' etc
ft. ft. CC
4.Date Well(s)Completed: _/S--;v Well ID# h' ft. K) I,(�
ft.
5a.Well Location:
Facility/Owner Name Facility ID#(if applicable) h• ft.
tZ©s ft. ft
c� W1 1 5`tv('
Physical Address,City,and Zip^~ ft. ft,
y It rO/Z 21r REMARKS
V
County ` Parcel Identification No.(PIN) U N .X 7 2 21
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: , Unit
(if well field,one lat/long is sufficient) 22.CertWic 'on: DVVR Secton
N W t
6.Is(are)the well(s) 'ermanent or Temporary Signature ofCertified Well Contractor Date
r 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: E3Yes orTVYo 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 ojthis 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-I is needed. Indicate TOTAL NUM_ BER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: V v (ft-) 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 1@1001 construction to the following:
10.Static water level below top of casing: 55 D (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
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: {'�/ l I� d,1 1 1\ 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: G 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) O Method of test: J (C1, 24c.For Water Supply&Infection 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 to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016