GW1-2021-06267_Well Construction - GW1_20211123

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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
Got. %
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for muld-cased welts OR LINER ifa livable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
I6.INNER CASING OR'TU RING eo m �,` ) '
Company Name d
l/�E�/v p thermal closed-loo
2.Well Construction Permit#:� �f/'/ � o FROM To DIAMETER 'rHICKNEss MATERAAI,
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 SLOTSIZE THICKNESS MATERIAL
Agricultural [3MunicipaVFublic ft. ft in.
Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single) ft. ft in.
Industrial/Commercial /Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. ft t
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL'PACK if a' livable
Aquifer Storage and Recovery [3Salinity Barrier E�rDLI
TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft.
Experimental Technology Subsidence Control ft-
Geothermal
(Closed Loop) Tracer G LOG attach additional sheets d necessary)
Geothermal(Heating/CoolingReturn ,Other(explain under#21 Remarks) TO DESCRIPTION color,hardness,wilimck e, in size,etc.fteJ4.Date Well(s)Completed: Well ID# )1Q f oWd tv,(I d
5a.Well Location:
Facility/Owner Name CFacility ID#(if applicable) f. ft
J25_q US —2 2 3
e ft. ft
Physical Address,City,and Zip !,r276 '9 ft. ft
HOC K'�f t CJ`� 21:REMARKS
County h�1 Parcel Identification No.(PIN)
O GE C I I(Jl 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(ifwell field,one IaVlong is sufficient)
22.Certification:
N W ` w
6.Is(are)the well(s)OPermanent or 13Temporary S of Certified Well Gdntractor 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: 13Yes or J?JlbW with I SA NCAC 02C.0100 or 1 SA 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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: Q� SUBMITTAL INSTRUCTIONS
'
9.Total well depth below land surface: S_ (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(examp e-3 200""and 2@1003 construction to the following:
10.Static water level below top of casing: 1/ D (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 Infection Wells: In addition to sending the form to the address in 24a
f'�� G)/Z ; above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: l 7 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: l 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: 1 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: /^ 0 _- 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