GW1-2021-04014_Well Construction - GW1_20210823

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King la:WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A S7 ft S f 'M
NC Well Contractor Certification Number
15OUTER CASING for multi cased wells TOR LINER if a livable
Aqua Drill, Inc. FROM TO DIAMETERTHICKNESS MATERIAL
Company Name ft. � ft 11�1f? S 0(u 1 1 P, J r C
16;INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: � FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, ariance•etc.) ft• ft in.
ft'
3.Well Use(check well use): ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft in.,
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) It. ft in.
Industrial/Commercial Residential Water Supply(shared)
1&GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft S 1
Monitoring E3Recovery ft. ft
Injection Well:
ft ft
Aquifer Recharge E3Groundwater Remediation
19.:SAND/GRAVEL PACK(if applies ble
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft %
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets'if:neces
Geothermal eatin Coohn Return Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,soiUrcek type,grain size,eta
{� Z) ft. l0 ft Sat 1
4.Date Well(s)Completed: Well ID# K,
ft. ft
5a.Well Location: 2 ft. it U izArj,}
LO -10 ft. ft
Facility/Owner Name Facility ID#(if applicable)
qO /-��iLwl^n�.s-� C'+ C�Mn;Iticx hAM y\Jr
Physical Address,,City,and Zip it 7 3(•,f 3 ft ft O
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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.Certitic tion:
N W � �- -
6.Is(are)the well(sPermanent or Temporary Signature of Certified Well Con for Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or No with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 well Construction Standards and that a
If this is a repair,fill out known well construction informati n 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: (B•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(a3200'and 2Q100� construction to the following:
10.Static water level below top of casing: .5 -0 (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: (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(�� 2♦ �' construction to the following:
(Le.auger,rotary,cable,direct push,etc.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) J Method of test: i 24c.For Water Supply&Iniectio�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: / 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
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