GW1-2021-04336_Well Construction - GW1_20210408

T'.�Print�form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
We1lContractor Name FROM TO DESCRIPTION
ft.
2080-A
ft. rt.
NC Well Contractor Certification Number 15:OUTER CASING for multi cased'wells OR LINER if ap licable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
D ft. ft- in.
Company Name '
©� _DD E FR'16.OM
INNER CASING OR TUBING' eottiermal closed-ES
2.Well Construction Permit#:/... L 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.
17.SCREEN
Water Supply Well: .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
]Agricultural �Municipal/Public ft. fa in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. N1 ` '
\ S
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
I Aquifer Recharge E3Groundwater Remediation
19.SAND/GRAVEL PACK if.a livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [IStormwater Drainage ft. ft.
Experimental Technology [3Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING.LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) r3 Other(explain under#21 Remarks) I
FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
O ft. ft- V,{
4.Date Well(s)Completed - -o ) WeWellID# ft. ft 5 oC 1
5a.Well Location: V ft' 7O St- &G I
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ft. ft
Ph ical Address,City,and Zip ft. ft. v
rF 21.REMARKS
County X Parcel Identification No.(PIN) 7
1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient)' ii i'ivi I i (; 'tl S:OHO 'il"i'] ills
22.Certification: '
4
6.Is(are)the well(S lPeimanen of•3Temporary' Signa re of Certified Well-Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.I&this a repair to an existing well' �Y¢S or/' IO with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
�'i in` co o this record has been provided to the well owner.
_- fthis is•n re�bir,fi!!out known'.ivel!construction information an_d'explairi the nature of the copy f
'ee,'air under#21 remarks s�;c)ion or on,tlie.back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For*Geoprobe/DPT or Closed-Loop.Geothermal Wells having the same
construction,only.1"GW-I is needed'•Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
dolled: SUBMITTAL INSTRUCTIONS
9.Total weil depth below fend surface: �0 00 24a. For Ali Wells: Submit this form within 30 days of completion of well
Far multiple wells list all deoths ifdifferent(example-3@200'.and2@100)' coIIstrnctioII to the following:
10.Static watir jevel•below top of casing: (O (ft) Division of Water Resources,Information Processing Unit,
If hater level is above casing,use^+/" ^'' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diamneter: (LJ' (in.) 24b.For Infection 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 constrdction method: /IZ"."(41 t ) construction to the following:
(ie.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) Method of test: 24c.For Water Supply&Iniectiori 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: 32 h 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