GW1-2021-06216_Well Construction - GW1_20210809

'� ,�rirlt Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Naive ft ,
2080-A C3'
ft. ft �
NC Well Contractor Certification Number 15,OUTER CASING for multi-cased'w`elis'OR'1,INER f aii Ucable
Aqua Drill, Inc. FROM TO DIAMETER THICIQYESS MATERIAL
ft. (_l Zft. in. e Z ' P
Company Name Lpy
t
f r' , 16'INNERCASING"OR TUBING eothermal dosed-loo '
2.Well Construction Permit#: t '" �1c! 'li GI fT 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. ft. in.
Geothermal(Heating/Cooling Supply) Mesidential Water Supply(single) ft• It.
Industrial/Commercial Residential Water Supply(shared) 18 GROUT
Irrigation FROM TO MATERIAL EMPLAC NT METHOD&AMOUNT
Non-Water Supply Well: Q n Q tt
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
17
Aquifer Recharge 13Groundwater Remediation
19:SAND/GRAVEL PACK Bs"liiatile
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. It.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG atti ch additional sheets if necessary)
Geothermal eatin Coohn Return Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soiVrock type,grains eta
it. ft o 1
4.Date Well(s)Completed:7-2;; •2/Well iD# 10 ft. CJ R
5a.Well Location: 51 ft- t
ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. fL
ft, ft. ,,#
�1Z�Lay" /2� C (c,�A-11 t C
Physical Address,City,and Zip ��Z� ft. ft.
21.REMARKS
County r Parcel Identification No.(PIN) N v��
0
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Ott wC r' n
(if well field,one lat/long is sufficient) 22.Certification: /��N W c��2�/1✓� , 2 T `
6.Is(are)the wefl(s)dRermanent or 13Temporary Signature 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: ®Yes or 13No 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 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: t LAS— (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: (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
/1 `� �� t 1 1 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: AI construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,GUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
I
13a.Yield(gpm) An Method of test: S CC yN 1J-- 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: Amount: lG (f) 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