GW1-2021-07067_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. fL
2080-A ft. fL
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL.
ft. fL CP j in. Z.4 Lv�
Company Name
16:INNER CASING OR TUBING "eothermal dosed-loo
2.Well Construction Permit#: O 10 U O 0 z I FROM To I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. fL In.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
IndustriaUCommercial ffResidential Water Supply(shared) 18.GROUT
hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft- • O It-
Monitoring 1311ecovery ft. ft.
Injection Well:
ft. fL
Aquifer Recharge [3Groundwater Remediation
19.SAND/GRAVEL'PACK if,ii`livable i
Aquifer Storage and Recovery E3 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. It.
Geothermal(Closed Loop) E3Tracer 2&DRILLING LOG attach additional sheets if necessary)
Geothermal eatln COOIIn Retum) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,wil/rock rain e' etc
k. ft. SQ l
4.Date Well(s)Completed/6 07- Well ID# 6 ft. Q ft. d O C
5,a.Well Location:
Facility/O�wner /me/ / Facility ID#(if applicable) ft. ft
t� ft. ft
Physical Address,City,and Zip fL % '
Dry 211tEM[ARKS
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.Certifica'On:
" N W
6.'Is(are)the well(sPermanent or 13Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E3Yes ortoNo 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 erplain 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
i
9.Total well depth below land surface: 76-S 00 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@100D construction to the following:
10.Static water level below top of casing:i n 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 Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: / /
- � -l/ above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(Le.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: S 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: �Z completion of well construction to the county health department of the county
where constructed.
Form GW-t North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016