GW1-2021-07066_Well Construction - GW1_20211129

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 44.WATER ZONES .
Well Contractor Name FROM TO DESCRIPTION
2080-A ft. ;z26 ft. 2 D 4,
y ft
NC Well Contractor Certification Number
15.OUTER'CASING for:multi-cased wells`OR'LINER ff a licsble
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
O ft. G fl- fllg. io. p x m yr
Company Name r
16 INNER CASING OR TUBING eotbermal closed-►oo '
2.Well Construction Permit#: 2 0 21'6oa Q.Sr C/ FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permrts(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 13MunicipaL/Public ft. ft. in.
Geothermal(Heating/Cooling Supply)residential Water Supply(single) ft n-
Industrial/Commercial [)Residential Water Supply(shared)
18 GROUT '
i bn atiOn FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. O ft �{
f
Monitoring Recovery It ft.
Injection Well:
ft. ft
Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEL PACK'if a licable "
Aquifer Storage and Recovery ®)Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [,Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.'DRILLING:LOG attachsadditionalsheets ifnecessa : .
Geothermal eaten Coolin Retum Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,wiltrock type,gnin size,etc.)
ft. ft- G
4.Date Well(s)Completed:./d ' L Well ID# h s )UL—ft t
ft. ft.
5a.Well Location:
j Facifi`//OO�wner N e Facility IDD)#(if applicable) ,+ h• ft
/7C4 JC.�,-J1 � )l �n 1fi 4 C Deo)l otti /J t 1. ft. ft
�ysical Address,City,add Zip -7 Z-X` ft. ft
1J f�%f d K� ! > [ 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.Certift lion:
N W
6.Is(are)the well(sPermanent or [)Temporary 9igfature of Certified Well Contractor---7 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: _®Yes or&I No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200,Well Construction Standards and that a
co o this record has been provided to the well owner.
lfthis is a repair,fill out known well construction information and explain the nature of the PY f P
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: (fL) 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 1@100) construction to the following:
10.Static water level below top of casing: ',2 0 (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
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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
t (
13a.Yield(gpm) �© Method of test: f 12 T 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:I" 8 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
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