GW1-2021-02255_Well Construction - GW1_20210521

Paint Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.'WATER ZONES
'
FROM TO DESCRIPTION
Well Contractor Name
t. 1'{ fL
2080-A ft. I ft.
NC Well Contractor Certification Number 15.OUTER CASING for multitased wells OR LIIHER if livable
Aqua Drill, Inc. FROM TO D1AlYlETER TM
I MATERIAL
0 ft 165 ft. in. $�' l J
Company Name 1
U / IC INNER CASING OR TUBING eothermal:closed-loo .
2.Well Construction Permit#: od ;2 rt a) FROM TO DIAMETER THICKNESS MATERLOLL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft. fL In.
3.Well Use(check well use): ft. ft.
Water Supply Well: 17.SCREEN
F ROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:'Agricultural [ Municipal/Public ft. & in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) fL ft. in,
Industrial/Commercial [IResidential Water Supply(shared) 18:GROUT
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ® ft. fL N t S
Monitoring Recovery 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 13Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 2&DRILLING.LOG attach additional Sheets if necessary),
Geothermal (Heating/Cooling Return) E30ther(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,soi1frock type,grain size,etc
Q ft. (3 IL
�t
4.Date Well(s)Completed Well EN o ft' ft. Q C K PA J
G{
\ '�
5a.Well Location: Q ft' ft' �s Z , - C
W t t'M0_-(^ """'�� )O i� �U\ ft. %
Facility/Owner Name Facility ID#(if applicable) ft. ft. t �.
ft. ft.
Mr
, R
)9p �K�II wwG C fL ft. w.�
Physical Addres City,and Zip
21.REMARKS
ounty �—�— Parcel Identification No.(PIN) ^ a Unit
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: D.Pv R S£CTlOn
(if well field,one lat/long is sufficient) 22.C�_U' no
N W
6.Is(are)the well(s) Permanent or 13Temporary Signature of Certified Well Contractor Date
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 olIgNo with 15A NCAC 01C.0100 or ISA 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#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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1,2 S_ 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 1@I00) construction to the following:
10.Static water level below top of casing: (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: Aln (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
/i 1 \ above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: A �2 ` 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: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Iniection Wells: In addition to sending the form to
11 1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: t0 0 Z completion of well construction to the county health department of the county
where constructed. f
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016