GW1-2021-02253_Well Construction - GW1_20210514

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:'
1.Well Contractor Information:
Chris King er'gi � 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A 4 ft (v I J �.
��1AY 1 ft. ft.
NC Well Contractor Certification Number n ProcesSing Unit 15.OUTER CASING for multi-VaiiW);wells OR LINER ifa Gcable 6„
Aqua Drill, Inc. 113tornM3t� ", e,ion FROM TO DIAMETER THICKNESS MA7 R.RiAI
ft' g� ft. in. g /
1 I v
Company Name 16 INNER CASING OR'TUBING eothermal dosed-loop)
2.Well Construction Permit#: l0 I O LcJ I'✓ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft• ft ,1n.
a•
3.Well Use(check well use): ft. ft. 'In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
I Agricultural 13MunicipaVPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft fL in.
lndustriaUCommercial DResidential Water Supply(shared) IS.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. .20 It. LV��r.\ 77L J C K
Monitoring 13Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEL':PACK if.a' livable "-
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. fL
Experimental Technology E3 Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach.additional sheets ifinecessa'
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness soiurock a Isla size,etc
ft. ft.
4.Date Well(s)Completed:,2 Well ID# ft. ft.
V ft. t. u
Sa.Well Location: O
ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
ft. ft.
Physical Address,City,and Zip
t is 21.REMARKS �p /,,,� �t /�
County Parcel Identification No.(PIN) S< ZL6�0 L C�16C/ Q e O� 1'/
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Z`S h&-1 W A-1r� l-r E 4L
(if well field,one lat/long is sufficient) 22.Certification-
N W `
�T
6..Is(are)the well(s) rmanent or Temporary Sign of Certified WrelFContractor j Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes orio with 15A NCAC 01C.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 remarks section or on the back ofthir 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: 77 C SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /��U (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@100D construction to the following:
10.Static water level below top of casing: 020 (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
n above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: f�//� �/Z j 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 Ce i nter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test:5,1 24c.For Water Supply&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: 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