GW1-2021-04300_Well Construction - GW1_20210430

' Pnt�Forrn
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A
L/ -/
ft, ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licabI
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
it. / ft / 1n.
Company Name 111101 C� to `
ii 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 1J20 0-3 /� FROM To DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. R. in.
3.Well Use(check well use): h• ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)MunicipaUPublic ft. ft. in.:
Geothermal(Heating/Cooling Supply) 42kesidenfial Water Supply(single) ft. ft. in.
IndustriaUCommercial DResidential Water Supply(shared) 18.GROUT
Irrl ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring DRecovery ft. ft.
Injection Well: ft. ft
)Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL'PACK if applicable)
111Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
J Aquifer Test E)Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock a fain size,etc.
ft. ft ,G
4.Date Well(s)Completed: 7 ' Well ID# ft. ft. r R.
�oc IC
ft.
5a.Well Location: S ft.`
ft
Facility/Owner Name Facility ID#(if applicable) ft. ft
ft � -- t:
Physical Address,City,and Zip ft. ft le
��1 1'tJ OIZo1 ( 21.REMARKS
nr^ APR . 2021
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 7.,O11 PCC: ;i"ll
(if well field,one lat/long is sufficient) 22.Certif ation
6.Is(are)the well(s)&ermanent or OTemporary Signature of Certified Well Contractor 15ate
�y� 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: [3Yes or 1l N0 with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
If this is a repair,fill out known well construction information Oan`d 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: ,oy2 9�.� (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@200'aand 1@100') construction to the following:
10.Static water level below top of casing: 2i n (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
�Q n above,also submit one copy of thisl.form within 30 days of completion of well
12.Well construction method:
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) S Method of test: J 24c.For Water Supply&Iniection Wells: In addition to sending the form to
J the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: T Amount: _Z 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