GW1-2021-05475_Well Construction - GW1_20210722

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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 DESCRtP,T1ON
2080-A ' itA0i G r
NC Well Contractor Certification Number 15OUI'ER CASING for multi-cased wells OR RIMER it a 'livable'
Aqua Drill, Inc. FROM TO DIAMETER' TRICKINESS I MATERIAL
Company Name It. ft t,�� in. <.1 (5
- '1 '16.INNER CASING'OR''TUBING"eothermallOdieed-loo v l.
2.Well Construction Permit#.-, O 4 -t-..�kJ Ct(�'�7 �� FROM TO DIAMETER TRICKINESS 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 [3Municipal/Public ft. tt in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) it. fL in.
Industrial/Commercial Residential Water Supply(shared)
1&GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. © ft.
Monitoring Recovery ft. ft
Injection Well:
ft ft
Aquifer Recharge 13Groundwater Remediation
l9SAND7GRAVEtiPAGK If,s llciib►e s„ * ' "„
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METH :�OD
Aquifer Test [3Stormwater Drainage ft IL J
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attachaddltlonifsh6WJf.necessa '
Geothermal ea' Cooliti Return Other(explain under#21 Remarks FROM I TO DESCRIPTION color,hardness,wiuroek tyM grains etc.
C�_�-'� J ft. %
4.Date Well(s)Completed:6��Z Well ID# '�K f" -6 it SArVd O r
5a.Well Location:� �r9 L,/�4 -Oft �-3 P t-ra ry 1 S � [n tlecZ
�W
.--tee ft. ft.
Facility/Owner Name
r ^ Facility ID#(if apf
plicable) ,i ft. It.
- 7 S
Pksical Address,City,and Zip �� ft ft •)
C ( ' � 21:REMARKS
rrrcL,cs ,
County Parcel Identification No.(PIN) t'Inn r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: e
N W
6.Is(are)the well(s) ermanent or Temporary Signature of Certified WeIrContractof Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accorda4----
7.Is this a'repair to an existing well: ®Yes or�No with ISA NCAC 02C.0100 or ISA 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:
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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:_ 30 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-33@200'and 2@I00) construction to the following:
10.Static water level below top of casing: tP o (ft.) t- Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' a;. 1617 Mail Service Center,Raleigh,NC 27699-1617
CO-11.Borehole diameter: ( (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
1 Z- \ above,also submit one copy of this form within 30 days of completion of well
12.Well construction method'' \ L+ 1 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) / 0 Method of test: C-0 24c.For Water SuDuly&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: completion of well construction to 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