GW1-2021-03033_Well Construction - GW1_20210622

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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
Rf /tt.
2080-A t�
R. It.
NC Well Contractor Certification Number 15.OUTER CASING for multl-cased wells ORLINER if a licable
Aqua Drill, Inc. FROM TO DIAMETER TIITCIQYESS MATERIAL
Company Name fL ISI ft 16 f/ in. 0?—;L` Jl
�Q ©�` '16.INNER CASING OR T[JBING eothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) It. 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. ft. in.
Geothermal(Heating/Cooling Supply) E!�Rksidential Water Supply(single) k. ft. in.
Industrial/Commercial Residential Water Supply(shared) I&GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: _
Monitoring Recovery R. M
Injection Well:
Non-Water
Recharge 13Groundwatcr Remediation
198APiD/GRAVEL:PACK.lies Ilcable �
Aquifer Storage and Recovery [3 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft. It.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessa
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,soilimck type rain size,etc
ft. ft-
4.Date Weil(s)Completed: 7 ' /Well ID# � ft. tt �L( C _ d
5a.Well Location: 2 R. 1` C C
I�rNe_ -l��-r,eS % R.
Facility/Owner Name /Facility ID#(if applicable)` 1 ,� ` ft. ft. t
.� Cog. l►�{ R. ft.
Physical Address,City,an Zi ft ft
lt7y_�Y r 1 21.REMARKS
County Parcel Idea ification No.(PIN) r e•the U 1t1
fli��I►r�``, it �G�t!nn
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifte lion: / 7
N W / ` -2-
6,Is(are)the well(s) ermanent or E3Temporary S ture ofCertified Well Contmc 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 or&5No with 15A 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 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: 5 ( ) 24a. For Ali Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@ 100) construction to the following:
10.Static water level below top of easing: (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
d?� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: f 12 construction to the following:
(Le.auger,rotary,cable,4grect 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: t 24.For Water Supply&Injection 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: O Z completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016