GW1-2021-04333_Well Construction - GW1_20210805

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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 DESCRIPTIONft it 3Q
2080-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING f6i'mtilti-ciiW Wells:OR LINER',fa licsT
Aqua Drill, Inc. FROM TO DIAMETER THICIQYESS MATERIAL
O ft / ft in.
Company Name SD
U '16 INNER'CASING'OR TUBING 'edthermal dwed400
2.Well Construction Permit#: l � FROM TO DIAMETER THICKNESS MA'rERLAL
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 13Municipal/Public ft. tL in.
Geothermal(Heating/Cooling Supply Residential Water Supply(single) ft ft in.
lndustrial/commercial DResidential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: /ai ft. ft. �
Monitoring Recovery v ft ft. ,
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL.PACK if;a..licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. fL
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer -2&DRILLINGLOG attach additional sheetsdf.necessa
Geothermal eaten Coolie Return) Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,sonfrock rain ' etc.
4.Date Well(s)Completed:?-2 -a Well ID# ft. S-S tL
5a.Well Location: 5—
ft. t �{fu C ls1Z .� C
fa b C-17 AowC1 1 ft
Facifity/Owner Name ` Facility ID#(if applicable) f. fL 2�
I 14 ' 1 r/t A l' lZ CI ft. ft
I l�.
Physical Address,City,and Zip ft ft tlOIR pro 011
5u J 1 21 REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: �7
N W
6.Is(are)the well(S),�f�Permanent or E37remporary S ature of Certified Well Contract r Date
P— 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 A10 with 15A NCAC 02C.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 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: e� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ✓ (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 2@100) construction to the following:
10.Static water level below top of casing: sv (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
r
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: /C2 dlC/1 / construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,iUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) c�V Method of test:5Iiin A 24c.For Water Supply&Iniechon 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: 42- 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