GW1-2021-06772_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM S ft. TO ft.
2080-A V
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased'wells ORLINER f a IIcsble
Aqua Drill, Inc. FROM % DIAMETER THICKNESS MATERIAL
ft. ft 6 io. z '/,
Company Name V
16.INNER CASING OR TUBING eothermal closed-loo
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. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
AgriculturalMunicipaVPublic ft. ft in•
Geothermal(Heating/Cooling Supply) � sidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Geothermal
ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. IQ ft.
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge E3Groundwater Remediation
19.:SAND/GRAVEL PACK if a licsbie
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft. ft.
Experimental Technology ®I Subsidence Control It. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG.attach additional iibeets if necessary)
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardy soillrock in s' etc
a ft. 6 ft. e �
jK-
4.Date Well(s)Completed. -�� Well ID# O fL ft- _ mud
5a.W 11 Location: 25-ft. To ft If ,Z N t
4 If
E c 9, (�('� Dore- ft. ft.
Facility/Owner Namey,�`f Facility ID#(if applicable) ft. ft. L.
Physical Address,City,and Zip ft. ft.
C A
J:\T:2C
`�e'z- 21.:REMARKS N q
County Parcel Identification No.(PIN) LJ
�fill�3$�"il 3;OI►
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certific 'on:
N W
6.Is(are)the well(sOp
ermanent or Temporary Signature ofCertifi We0 ntractor 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 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 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5-®s- (R•) 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@1001 construction to the following:
10.Static water level below top of casing: (O O (tt.) 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 Injection Wells: In addition to sending the form to the address in 24a
` 1 ' above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1 2 D tZ1 J construction to the following:
(i.e.auger,rotary,cable,direct pushy etc.) l
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: C 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: S l 1 24e.For Water Supply&Injectlon Wells:' In addition to sending the form to
TT Z the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: V 0 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of finvironmental Quality-Division of Water Resources Revised 2-22-2016