GW1-2021-07057_Well Construction - GW1_20211129

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name � ft. Ilk
2080-A
fL fL
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased we0s OR LINER if;a' IIca61e
Aqua Drill, Inc. FROM To I DIAMETER I THICKNESS MATERUL
Company Name O ft M , in. ,
� ' 16ONNER CASING OR TUBING" eotherriial closedNES
2.Well'Construction Permit#: llG'� FROM To DIAMETER TalcxivEss MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) R. fL in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 11 SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) tesidential Water Supply(single) fL ft.
Industrial/Commercial Residential Water Supply(shared)
<18.GROUT ,
hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: fL v fL ,,
Monitoring Recovery ft. tL
Injection Well:
_ ft. ,..._ ft.
Aquifer Recharge [3Groundwater Remediation
l9:'SAND/GRAVEUPAGK`it,a 'lieiitile � - _;"'�", "��.,. ;� •„
Aquifer Storage and Recovery ®ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �Stormwater Drainage ft. tL
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING:LOG ettseti additional sheets it necessa '
Geothermal(HeatingtCoolng Return) Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,solUrack type,grain size,eta
--11 ft. ft.
MAY
4.Date Well(s)Completed: �� o` Well ID# ft. fL d ©GI
5a.Well Location: S ft- SQL UG /Z vti
ft. ft.
Facility/Owner Name Facility 1D#(if applicable) ft. ft.
c�1 13
Physical Address,City,and Zip 7341 h' ft. N O V 2
21.REMARKS
County /v Parccl Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certlfica' n:
Q
N W "Oe - Z Q -/ ^ 2 /
6.Is(are)the well(sl6ermanent or OTemporary Si of Certified Well Contractor Date C
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: ®Yes or Mo with 15.4 NCAC 02C.0100 or I5A 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: (O a. (N 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@2200'and 2@1001 construction to the following:
10.Static water level below top of casing: tO 0 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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
n n J 2; above,also submit one copy of this form within 30 days of completion of well
L 12.Well construction method: /Z / C; 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) ! Method of test: 24c.For Water SunDly&Iniection Wells: In addition to sending the form to
J the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: T Amount:.2-4 d Z. completion of well construction to the county health department of the county
where constructed. 1
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016