GW1-2021-06217_Well Construction - GW1_20210809

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
Chris King 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 1 �/ It.
O 1
2080-A I sC
.'L6 eft• 126 1 ft-
NC Well Contractor Certification Number 1 15.OUTER CASING for multi-cased'wells OR LINER(if ap licable
Aqua Drill, Inc. FROM TO DIAMETER I THICKNESS I MATERIAL
Company Name ft yg in. !,D n �1 t
16 INNER CASING OR TUBING` eotherivaIA6kd400 ;
2.Well Construction Permit#: '©�l -W k��f-—O 3 9 3' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) Amft ft.
3.Well Use(check well use): ft• ft.
Water Su 17.SCREEN
PPIy Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft O fL C
Monitoring Recovery ft. ft
Injection Well: ft. ft
m
Aquifer Recharge 13Groundwater Reediation
19.SAND/GRAVELPACK if.a` licalile
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.:DRELLING.LOG attach additional sbeets if necess
Geothermal(Heating/CoolingReturn Other(explain under#21 Remarks TO DESCRIPTION(color,hardn soillrock a s etc.
4.Date Well(s)Completed:�� Well ID# V tt � d or,5a.Well Location: on ).2 ft 3)V
ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft
©7LC'TA S nA; Ed /sZeenKholz o YU R. ft
Physical Address,City,and Zip 97 Lliv f'7 ft ft O
ho► c 21:REMARKS
r�GL•,cS1 ,.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certification:
N W
6.Is(are)the well(s) Permanent or Temporary ature ofCert' ed Well Contractor I Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes orANo with 1 SA 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
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9.Total well depth below land surface: ✓&2 -5— (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifeli ferent(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: Ll)
o (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
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: A 1 Z-1, 1 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
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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: _ 24.For Water Suably&Infection 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: NTh Amount: iC n Z. completion of well construction to the county health department of the county
where constructed.
Forth GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016