GW1-2021-03917_Well Construction - GW1_20210823

t� Print Forme
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
ft. 51 ft.
W
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells'OR LINER if
a icable
Aqua Drill, Inc. FROM TO DIAMETER THICLINESS MATERIAL
O 1z / v C
Company Name %%� r
16:INNER CASING OR TUBING eothermal dosed- S
2.Well Construction Permit#: J (D//
E17.
M TO DIAMETER THICKNESS MATERIAL,
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft it. in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: M TO DIAMETER SLAT SIZE THICKNESS MATERIAL
Agricultural [)Municipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) AResidential Water Supply(single) ft, fL ;a
lndustrial/Commercial Residential Water Supply(shared) 18.GROUT
llrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. O ft G
Monitoring Recovery ft. ft
Injection Well:
ft. ft.
LJ
Aquifer Recharge Groundwater Remediation
19 SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3 Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20,DRILLING LOG attach additional sheets U necessary)
Geothermal(HeatinglCooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION color,ha dad soiltrwk a rain size,etc
ft. ft G(
4.Date Well(s)Completed:_ Well ID# ft• ft K J R
Sa.Well Location- ft. 3
L0 Cft
Facility/Owner 14ame Facility 1D#(if applicable) ft. ft
' ft ft a9
pir�1 r �)rarer 5�c tt2 ru
Physical Address,City,and Zip !C4 Ct ft. ft
L,ROA L/ l 31.REMARKS t.
County Parcel Identification No.(PIIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r31,C '�crt.rJ�
(if well field,one lat/long is sufficient) 22.Cer'tifieati n•
N W _
6.Is(are)the well(s)1IPermanent orTemporary Si re ofCertified 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 1-so 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 informatiin 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: C_ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: O 5 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-33@200'and 2@100D construction to the following:
10.Static water level below top of casing: (o 0 (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:. K-1 _-(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: fir' C IZ 1 l I construction to the following:
(Le.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
13a.Yield(gpm) / .S Method of test: 24c.For Water Supply&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: Amount:,,) 0 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