GW1-2021-06268_Well Construction - GW1_20211123

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
i
1.Well Contractor Information: +
Chris King 14.WATER ZONES p
FROM TO DESCRIPTION
Well Contractor Name 3Ci�ft. 2 tt
2080-A l .7
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells'OR hINER -e Rble
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name c
C_� INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: J ZS 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 C]Municipal/Public ft, ft, in.
Geothermal(Heating/Cooling Supply) DeResidential Water Supply(single) ft, ft in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ® ft. ft
Monitoring Recovery ft. ft
Injection Well:
It, ft
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft %
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets.if uecessa
FROM TO DESCRIPTION
Geothermal(Hearin Conlin Return Other(explain under#21 Remarks ft haN color, rdn soil/roek ins etc
ft.
,44
4.Date Wells)Completed: Well ID# ft' S s ftyu ROC K
5a.Well Location: C 0`009 � ft ft 20 I,r,
ft' ft 6140d OoC K
acility/Owner Name Facility ID#(if applicable) ft- sft 6Z n Jt `o
16 L -7 ( ft. ft
Physical Address,City,and Zip rl/'C '��6S a ft. ft
21 REMARKS n
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: NOV 2 3 2p
(if well field,one latAong is sufficient) 22.Cerdflcati
N W
6.Is(are)the well(s) Permanent or Temporary Signature of Certified We0 Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance.,_
7.Is this a repair to an existing well: E3Yes or INNo 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 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: �f��� (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@^2-0�0'and 2@100D construction to the following:
10.Static water level below top of easing: / (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"++ 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: GD (in.) 24b.For Iniection Wells: la 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: /7/ /L ///Z 1 l I 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: C 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) C7 Method of test: J 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:J ). O 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