GW1-2021-04390_Well Construction - GW1_20210805

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Contractor Information:
Chris King 14i WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A 5�`' S(ft OC 4/11(�.rn
e It
NC Well Contractor Certification Number
IS.OUTER CASING for mald-cased wells OR LINER'ifa Gcable
Aqua Drill, Inc. FROM TO DIAMETER THICKINESS MATERIAL
O ft it �g in-
Company Name
16.INNER CASING OR:T[)BING(geothermal dosed-loo
2.Well Construction Permit#: S S(G`b 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 [3Municipal/Public ft, M in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft, ft. in. i
Industrial(Commercial DResidential Water Supply(shared) 1&`GROUT
Ilrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: tJ ft. /9 0 ft
Monitoring Recovery ft. ft.
Injection Well: ft, ft
Aquifer Recharge 13Groundwater Remediation
;19 SAND/GRAVELzPAGK-ifii"liceble
Aquifer Storage and Recovery [3Salinity Battier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage fL ft
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer M DRILLING LOG attach additionatsheets if necessary)
Geothermal eatin COolin Return Cl Other lain under#21 Rcrnmics FROM TO DESCRIPTION mlor,hardness,soiVroek rain a' etc
o ft. 6 ft /Z� d I A
4.Date Well(s)Completed: /Well ID# 6 ft 0 it
5a.Well Location: 76 ft. IS S ft-
ft
Facility/Owner Name 'I Facility lD#(if applicablee)i� R' it.
71 m 12/"e t 14W Z F7�Jz3gU=? r/�r t / ft. ft
Physical Address,City,Jand Zip ✓1 ft. ft
ra w(l/L �f Y C i1:REMARKSsow
r o `
unty Parcel Identification No.(PIN) j PA
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Pry
(if well field,one lat/long is sufficient) 22.Certification: vr%iolllio
Q`i`�R
f
N W a?o�? -
7- ;2) -�/
6.Is(are)the wells) er manent or Temporary Signatu 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: [3Yes or ElNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out!mown 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: ' (ft) 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 2@100) construction to the following:
10.Static water level below top of casing: L f'y (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: y (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
R 1 �Z;�\ above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: to t C construction to the following:
(Le.auger,rotary,cable,direct push,etc.) f
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I
13a.Yield(gpm) 26 Method of test: t 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: JY141 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