GW1-2021-05546_Well Construction - GW1_20211013

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ,��� �'
Chris King 14.WATER ZONES
Well Contractor Name c FROM TO DESCRIPTION
2080-A K rip
v a�lCt�U t D k ? ft. M
tOI1
NC Well Contractor Certification Number ,(;3 I SCsC�
� 1ro5.DOUTER CAS ING for inDIAMETER wells)
OTH[CKNESS a hMAiTERiAL
Aqua Drill, Inc. ^
Company Name V ft. (4 % yg io. 51'I ZU )_3 V,6
16.INNER CASING OR TUBING" eotherinat closed-loop)
2.Well Construction Permit#:�XW` 10 0 1,2— FROM I TO I DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Yariance,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.f=: in.I
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) g ft, in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft. O ft- �
Monitoring 13Recovery ft. ft.
Injection Well:
(t
Aquifer Recharge 13Groundwater Remediation
19.SAND/DI GRAVEL PACK if applies hle'
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology [ Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,wlif ck rain e' etc
Geothermal(Heatin Caolin Return) Other(explain under#21 Remarks
2 e J I
4.Date Well(s)Completed: � ' Well ID# �p ft' �. ft S ri rJa O C K.
5a.Well Location: ft.
ft. ft.
Facility/Owner
�Name I ,�Facility ID#(if applicable) �t ft. ft.
v 61 N/ /dn 14 Jz C / I' I FagaI,onJ N •` ft. ft.
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Ph sical Address,City,and Zip ol(7 ft. ft.
d
21.REMARKS
County t Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification'
N W f "7 �f I
6.Is(are)the well(s) Permanent or 13Temporary Si n!`ofCertifieJ Well ContractorJ 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 OM�No 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 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / 00 24a. For All Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depths ifdi,[jerent(example-3 200'and 2@I00) construction to the following:
10.Static water level below top of casing: 7 (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
�
J above,also submit one copy of this form within 30 days of completion of well
,/�
12.Well construction method: �l 1'l L Zt 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: t 24c.For Water Supply&Iniection 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: completion of well construction toI 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