GW1-2021-07346_Well Construction - GW1_20210921

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14 WATER ZONES
FROM -.
Well Contractor Name TO DESCRIPTION
ft. /07 ft 5� i f�►K
2080-A
ft. ft.
NC Well Contractor Certification Number 15 OUTER CASING for multi-cased'wens;PRUNER ifa Iicable
Aqua Drill, Inc FROM TO DIAMETER' THICKNESS MATERIAL
Company Name 6? ft. 166 ft 6 in. j SIP
16.INNER CASING,OW4T ING eofhermal closed-loo
2.Well Construction Permit#: Y (Q G.(/ I / 1 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
Water Supply Well: 17:+SCREEN
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. ft. in•'
Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) M GROUT
Irrigation FROM TO MATERIAL EMPLACE
MENT METHOD&AMOUNT
lGeothermal
on-Water Supply Well: ft. ft. Q G t
Monitoring Recovery ft. %
jection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19:SAND/GRAVELTACK?if a`lieiitile ?� =ul
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ElStonnwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer '20.DRILLING LOG attach additionafaheets'if;uecessa' '
(Heating/Cooling Return) InOther (explain under#21 Remarks) FROM TO DESCRIPTION color,hardnesN soiltrock type,grains eta
© fL AD ft- Red; (41
4.Date Weil(s)Completed: -3�-z�Well ID# I d t3 1(3 ft' 6 ft h J Gj ILA
5a.Well Location: k. m�
ft. ft.
Facility/Owner Name / Facility M#(if applicable) ft. ft.
tZ 12- J ft. ft 2�
Physical Address,
�Citty,,.and
oZip ft ft. A
&M 4r`� 21 REMARKS . ¢Or
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
N W
6.Is(are)the well(s) ermanent or Temporary Signature of Certified Well 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: Oyes or E f N0 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: C� _ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �✓ (R•) 24a. For All Wells: Submit this i form within 30 days of completion of well
For multiple wells list all depths it different(example-3@200' d 2@100),- construction to the following: j
10.Static water level below top of casing: U (ft.) Division of Water Resources,Information Processing Unit,
ljwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
/1 i r7 ��'(/ above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: /i 1� 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 Supply&infection,Wells: In addition to sending the form to
d the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: -1 l7 z•- completion of well construction tol the county health department of the county
wheie constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I.