GW1-2021-05553_Well Construction - GW1_20211013

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: Two
Chris King �� 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
(120 vz ft G► 9,
2�8�-A li�f0 Jew�111� ft. ft.
NC Well Contractor Certification Number �C1,3= �li�� Jp^1'•D� 15:OUTER CASING for multi cased wells UR,LINER.if a livable
Aqua Drill, Inc. O� FROM TO DIAMETER THICKNESS MATERGIL
Company Name ��
O ft. ft. (% i in. 50 , ✓l�
16:INNER CAS GOR TUBING eothermal 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• h' in.
3.Well Use(check well use): ft. ft.17.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 11 Altmidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18 GROUT
Irrigation FROM TO MATERIAL r EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. V ft. �)r-' c t
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL-PACK.If.a livable '
LJ
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®IStormwater Drainage ft. ft.
Experimental Technology 13 Subsidence Control ft. It.
Geothermal(Closed Loop) Tracer 20.'DRILLINGLOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/o k type,grain size,etc
O ft. —ft-
�( ` ,, y
4.Date Well(s)Completed:9 I?+�)Well ID# ft' 7 It 5191N (ZOC R-
5a.Well Location: ft. it
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft, fL
/ , oo(L e L// ri ('l J ft. ft.
Physical Address,City,and Zip ft. ft.
o f/ 21.REMARKS
County �i• 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
6.Is(are)the well(s)dnrmanent or Temporary Signature of Certified Well-Contrac[r Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or allo with ISA NCAC 02C.0100 or ISA 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: �J (� 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 ifdifferent(example-33@2000''and 2@100) construction to the following:
10.Static water level below top of casing: `/ (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: 24b.For Iniection 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: A I TZ d lli I ( construction to the following:
(i.e.auger,rotary,cable,direct pushy 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: 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:�!� 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 I Revised 2-22-2016