GW1-2021-00882_Well Construction - GW1_20210402

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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 �. 61
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased'wells'OR LINER if a licable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Dft. ft. �g in.
Company Name ,
16;INNER CASING OR:TUBINM eothermal;HICK-ES'
2.Well Construction Permit 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 Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
_
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irri ation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft
3 Monitoring DRecovery,
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL'PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) ]Tracer 21 DRILLING LOG;attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) _Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,wilfrock rain size,eta
k. ft-
t e 1
4.Date Well(s)Completed-3 0 oC Well ED# ft. 5Q IL Z� K
5a.Well Location: ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft
ft. "
Ph 'cal Address,City,and Zip 3;/ R' ft.
(Q 21 REMARKS
County Parcel Identification No.(PIN) nit
Into � r r v
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: pvjgecftn
(if well field,one lat/long is sufficient) 22.Certification:
N W 1 `-3 6 ,2 /
6.Is(are)the well(s)6ermanent or OTemporary Signature of Certified VVell Conifactor 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• E]Yes or�Pio with ISA 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 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 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: 7 S (ft-) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths:)different(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: 150 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
,J above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 'd;l Z Ci/Z r^� 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: 5! 24.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:/2 o Z 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