GW1-2021-05486_Well Construction - GW1_20211013

t W,ELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.tl Contractor Information:
C ris King PEc 14.WATER ZONES
ell Contractor Name FROM TO DESCRIPTION
2080-A (1Cj 1 2021 `$ ft 3 r01
e.
NC Well Contractor Certification Number {1 prc
cassir�9 Uri ft
IU;Gr1r3�t0 tot, 15.OUTER CASING for multi-cased wells OR LINER rf a Iicable
Aqua Drill, Inc. p�N� FROM To DIAMETER TIIrcIQYEss MA7 RRiAI.
ft. 1 V3 ft. in. gS
Company Name
��� 16:INNER CASING OR'TUBING' eothe- I closed-loop)
2.Well Construction Permit#: 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.
Water Supply Well: FROM REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural DMunicipa/Public ft. ft in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft in.
Industrial/Commercial Residential Water Supply(shared) IS.GROUT
IIr'1 ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft. ft `
Monitoring Recovery ft. ft
Injection Well:
k. ft
Aquifer Recharge 13Groundwater Remediation
19.SAND/GRAVEL:PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft
Experimental Technology 0Subsidence Control ft. ft
Geothermal(Closed Loop) ®ITracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal eatin Coolie Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,Hardness,soiltrock in s etc
ft ft p
k. ft p
4.Date Weil —�,3;
(s)Completed. I Well ID# 5
Sa.Well Location: 346
ft. 31 ft ►uC 1
ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft
,,72,! V jro 4 e lz &J ft. ft
Phy ical Address,City,,andZip ft ft
M/� C 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.Certitica n:
N W 0z3-� 1
6.Is(are)the well(s) ermanent or Temporary Signature of Certified e11 Contras or 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 No with ISA 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: ? e SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J z5 (N 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: �C/ (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: CD (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: 17_�2 i � 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
13a.Yield(gpm) ✓ Method of test: s• _ 24c.For Water Suauly&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 ithe county health department of the county
where constructed.
Forte GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I