GW1-2021-04013_Well Construction - GW1_20210823

Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
D t.
2080-A f '
10
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING'for T!!L11 ed wells ORiLINER if a licable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS M�AAT'ERUL
�Company Name ft O ft I in. De I ! ' ✓' C
46.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:/7 I '..[ O 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 Municipal/Public ft• ft. in.
Geothermal(Heating/Coofing Supply) Residential Water Supply(single) ft ft in.
Industrial/commercial Residential Water Supply(shared) 18.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft 112. O tt C `t
c
Monitoring Recovery ft. ft
Injection Well:
I Aquifer Recharge Groundwater Remediation ft. ft.19.SAND/GRAVELTACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft ft
Experimental Technology 13 Subsidence Control ft ft
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets If necessary)
Geothermal(Heating/CoolingRettrm Other(explain under#21 Remarks FROM To DESCRIP fION rnlor,bards soil/rock etc
k. ft
4.Date Well(s)Completed: —.2 Well ID# ft ft
Sa.Well Location ft gs tt LJ cl C 1 C
ft. ft
l-'
Facility/Owner Name Facility ID#(if applicable) ft. fL •��
J ft. ft
ft ft
�� L,� j�
Physical Address,City,and Zip )
Zl:REMARKS
County Parcel Identification No.(PAN) r'rnC
c r��0•i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certifica On:
N W 'r
6.Is(are)the well(s) ermanent or Temporary Signature of Certified Well Contraci 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 iffNo with ISA NCAC 02C.0100 or ISA 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: pp �/ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 0 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all Sfepths ifdijjerent(example-3Q200'and 1Q1001 construction to the following:
10.Static water level below top of casing: -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 Iniection Wells: In addition to sending the form to the address in 24a
- Zi '\ above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
t
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
I
13a.Yield(gpm) Method of test: 1 24c.For Water Supply&Iniect ion Wells: In addition to sending the form to
the address(es) above, also submit bne copy of this foam within 30 days of
13b.Disinfection type: 1J1 H Amount: Q © Z_ completion of well construction to the county health department of the county
where constructed. I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource's Revised 2-22-2016
I