GW1-2021-05911_Well Construction - GW1_20211025

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name G � � r>
2080-A / l Y- 5 •L
k. ft.
NC Well Contractor Certification Number 15.,OUTER CASING for multi-cased wells OR LINER ap Iicable
Aqua Drill, Inc. FROM I To DIAMETER THICKNESS MATER.IAAL
0 ft. it. in. 50Z t v
Company Name c7 C/
`16 INNER CASING OR TUBING eothermai dosed400lij
2.Well Construction Permit#: ao 0 06U FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. f6 In.
3.Well Use(check well use): ft. ft, in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3MunicipaL/Public k. ft. in.
Geothermal(Heating/Cooling Supply) ffResidential Water Supply(single) k. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 58 GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft- O fL On2d—wik—* "S
Monitoring 13Recovery ft. fL
Injection Well: ft. ft.
Aquifer Recharge 13Groundwater Remediation
19:SAND/GRAVEL PACK if:a Iicatile '
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. It.
Experimental Technology 13Subsidence Control ft. fL
Geothermal(Closed Loop) Tracer 20.'DRIILLING LOG attach additional sbeets.if:necessa
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillmek tyM grain size,etc
k. ft- X c
4.Date Well(s)Completed: [q..-23_ Well ID# ft. g Q ft (bIJ C
5a.Well Location: U ft. tt t1 e
FL ft.
Facility/Owner Name Facility ID#(if applicable) fL
ae
S`"7 7 5t t �,�o C.Ji4; mAa✓ 9,4
k. fLvo
Physical Address,City,and Zip /\/
) �e)j t.- 1q 1?aru (J,� L
d ;On2q ft' ft
Il L1 1 S(�Y 21.REMARKS
County Parcel Identification No.(PIN) "AQ
Fj\\t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
iO�S
(ifwell field,one lat(long is sufficient) 22.CertifiC 'on: W+1010 O�Rge
N W T "
6.Is(are)the well(s) Permanent or 13Temporary Signature of CeMfied Well Contractor 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: ®Yes or o?No with 15A NCAC 02C.0100 or 15A 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-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 ifdijjerent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: (k.) Division of Water Resources,Information Processing Unit,
Ifwater 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: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
k
13a.Yield(gpm) ._ O Method of test: i 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: 6 d 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 Revised 2-22-2016