GW1-2021-04457_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 DESCRIPTION
2080-A
ft. fL
NC Well Contractor Certification Number 15.OUTER CASING forroulti-cksed'we11s:OR-LINER If a licable '
Aqua Drill, Inc. FROM TO DIAMETER TIIICtINE3S MATERIAL
ft. 1103
ft- G in'
Company Name
�\©t (, / '16 INNER CASING OR TUBING` eo'thermal d6o W400"
2.Well Construction Permit#: I -j l FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft la.
3.Well Use(check well use): ft. M in.
Water Supply Well: 17.:-SCREEN
pp y FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL,
Agricultural [3Municipal/Public ft, fL in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
Industrial/Commercial Residential Water Supply(shared) I&`GROUT::
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. fL -
Monitoring pRecovery ft. ft.
Injection Well: ft. ft
Aquifer Recharge Groundwater Remediation
19 SAND/GRAVEL PACK`ff s"lieable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology J3 Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.:DRILLINGJOG attaeh`additional sheets ifnecessa
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,soiltromli typp,grain size,etc
ft. fL r
4.Date Well(s)Completed: Well ID# / ft' ftft /toc
Sa c Well Location: 75 ft ^ / �U Cat v j
ft. ft.
�Facility/Owner Name Facility 1D#(if applicable) ft. ft.
ft. ft
b� l 17t�luht-InT i'l tdG� �d/0{) ft. ft. r�
Physicaland Zip �v_G
e h In xn 21::REMARKS.
l ;ii, process fi
County Parcel Identification No.(PIN) n
pWR e .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s) Permanent or Temporary Si4f51Ci;iZ,5:'PWell Contractor 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 o with 15A 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 Aplain 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 thisform.
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: 3.24 (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: 40 0 (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: C� (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
n i J above,also submit one copy of thisform within 30 days of completion of well
12.Well construction method: f' ��G Q 1 J construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLYMELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
t
13a.Yield(gpm) Method of test: ht 24c.For Water Supply&Infection Wells:1 In addition to sending the form to
/;� the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfecti6n type: Amount' completion of well construction to the county health department of the countywhere constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016
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