GW1-2021-03918_Well Construction - GW1_20210823

� ��P.rint 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
2080-A o ft r`' O rac
rt. ft
NC Well Contractor Certification Number r t
IS.OUTER'CASING for multi cased'wells OR LINER if a cable
Aqua Drill, Inc. FROM TO DIAMETER THICIINESS MATERIAL
ft. 30 ft in.
Company Name �v
^ 16.INNER CASING OR TUBING eothermal el0sed-loo
2.Well Construction Permit#: . 6�� FROM TO DIAMETER THICIINESs MATERIAL
'X 6
List all applicable well construction permits(.e.UIC,County,State,Variance,etc.) ft in.
3.Well Use(check well use): ft. ft. In.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. ft in.l
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft % .V C.
Monitoring DRecovery ft ft
Injection Well:
ft ft
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery ®ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft
Experimental Technology Subsidence Control R. ft
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG attach additions]sheets if necessary)
Geothermal(HeatinglCooling Return Other(explain under#21 Remarks FROM TO DESCRIPTION color,bardness,soi0rock tyM grain size,etc
ft 8 ft
4.Date Weil(s)Complete 62 A ( Well ID# M � ft
5a.Well Location: CK %;) ft S'ft
ft ft
Facility/Owner Name p^ Facility 1D#(if applicable) ft. ft
ft. ft
Psal Address,City,and Zip �- ft ft
h si 21:REMARKS
County Parcel Identification No.(PIN)
5
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
dwell field,one lattlon is sufficient c^n Vr"fly
(� g� ) 22.Certification: 3,.:•• ���.^..`
,,,.,/ N W _
6.Is(are)the well(sermanent or Temporary rgnature of Certified well Contras r Date
o 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: [31es or A6 0 with 1 SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy ojthis 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 I GW-1 is needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: l y SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ! ` (M) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdifferent(example-3(a3200'and 2 100) construction to the following:
10.Static water level below top of casing: -30 (ft.) Division of Water Resources,Information Processing Unit,
Ijwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
^r ) I above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: fit/7— / < / construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
, I
13a.Yield(gpm)_c2 n Method of test: 24c.For Water Supply&Infection Wells: In addition to sending the form to
U the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:ffA Amount:1a 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