GW1-2021-04309_Well Construction - GW1_20210430

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King ,T17 14.WATER ZONES
Vz
Well Contractor Name >t" iV s,,,, FROM TO DESCRIPTION
2080-A d fL S
r
�� 2021 ft. rL
NC Well Contractor Certification Number APR 15.OUTER CASING for multi-cased wells OR LINER if a licable
Aqua Drill, Inc. ^�^ r,F,J��E 81Cc�t.j1�11 FROM TO DIAMETER THICKNESS MATERIAL
rt. /' ft. l d ! in.
Company Name 1 i:Ur „-,f�J`v �j;Q f0 �O V r C
2-7�� j 76.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: J J�l� "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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural rIMunicipaVPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in,
_i Industrial/Commercial [IResidential Water Supply(shared) 18.GROUT`
_ Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. It. `
Monitoring_ _ _Recovery ft. ft.
Injection Well:
ft. ft
1 Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEL-PACK if applicable)
f Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
'Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
J Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional sheets if necessa,'
FROM TO DESCRIPTION color,hardness,soir/mck e, rain size,etc.)
Geothermal(Heating/Cooling Cooling Return) Other(explain under#21 Remarks)
ft. ft. �fZ
4.Date Well(s)Complete� Well ID# ft. ^R e 154.
G ` e
ft. ft.
Well1 Location:
C
' Facility/Owner Name Facility ID#(if applicable)
rt. ft.
3/-7 2 f-I(7�� �� deroke-<ati2 ICU �� rt. rc
Physical Address,City,and Zi a7� �� ft. ft.
21.REMARKS
County 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 (1-113
6.Is(are)the well(
sQPermanent or Temporary Sign re of Certified 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 [N�le- 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 ofthe copy ofthis 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1z12 _S� (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 2@I00') construction to the following:
10.Static water level below top of casing: V.,2O (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
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method- od/ /C.7 L-_�tz f z/ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) f
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) J Method of test: 24c.For Water Supply&Injection 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: 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