GW1-2021-06160_Well Construction - GW1_20211025

'' i��int Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
ft.2080-A
NC Well Contractor Certification Number 7d 17-Zft. G �' &I
I5.OUTER CASING for I riultincased wells OR LINER;d a licable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. I� in.
Company Name
16 INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#:
z 1©� ..Q U FROM TO I DIAMETER THICKNESS MATERIAL
1
List all applicable well construction perinhs(i.e.UIC,County,State,Variance,etc.) it.
fL 1°• / r�J
3.Well Use(check well use): ft. ft.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER'. SLOT SIZE THICKNESS MATERIAL
:')Agricultural [3Municipal/Public tt, ft, in.
Geothermal(Heating/Cooling Supply) JUSesidential Water Supply(single) ft ft. iR
Industrial/Commercial Residential Water Supply(shared)
]8.'GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 6 iw 7 i ; `
Monitoring Recovery ft. ft. 7
Injection Well: ft. ft.
Aquifer Recharge 13Groundwater Remediation
r-AAquifer Storage and Recovery Salinity Barrier 19 SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft• it
Experimental Technology 13SubsidenceControl ft. it
Geothermal(Closed Loop) Tracer 20.DRILLiNG.LOG attach additional sheets if necessary)
Geothermal (Heating/Coo Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrock type,grain si etc.)
�A1 ` ft.Well Date Well(s)Completed: -)6 s I Well ID# ft• � fL
5a.Well Location: ft.,, ft 11 e Z e
Facility/Owner Name ', r ,p J Facility ID#(if applicable) ft, ft.
616 43,r �t� ��tZ ft. ft.
Physical Ad�d/Z,City,and Zip ft tL
10 �'h 1 r`A.���M 2L REMAItKs n Q
County �— Parcel Identification No.(PfN) WR$BCt10I1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certiftca' n:
N W - -- o
6.Is(are)the well(s)IgPermanent or ®ITemporary Stgmilure of Certified Well CoAactor 0 Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
1.Is this a repair to an existing well: Dyes or o 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 I 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: / lS (ft•) 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 1@100) construction to the following:
10.Static water level below top of casing: G�� (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 Infection Wells: In addition to sending the form to the address in 24a
,Q j above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: o` ki construction to the following:
(te.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 276994636
13a.Yield(gpm)— Method of test: 24c.For Water Supply&Iniectiof Wells: In addition to sending the form to
the address(es) above, also submit I one copy of this form within 30 days of
13b.Disinfection type: Amount: 7- completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources ! Revised 2-22-2016
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