GW1-2021-07350_Well Construction - GW1_20210921

Pnn' rm t Fo
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
2080-A 170ft. 751t o o t
ft. fL I
NC Well Contractor Certification Number 15.OUTER CASING'for multi-casedl wells 0R L1NER a ticeble
Aqua Drill, Inc. FROM To DIAMETER THICKNESS MATERIAL.
it. It. in. p �[
Company Name
^� � /�f� FROM ER CASING OR'TUBING
AM eothermafIUCK ES
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERiAI.
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 I I BLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. ft in.'.
Geothermal(Heating(Cooling Supply) sidential Water Supply(single) ft ft
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. 620 fL
Monitoring DRecovery ft. ft
Injection Well:
ft. ft. 1
Aquifer Recharge E3Groundwater Remediation
19.SAND/GRAVEL PACK'if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD'
Aquifer Test [3Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft %
Geothermal(Closed Loop) Tracer 20;DRILLING LOG attach additional sheets'ifinecessa
Geothermal(Heating/Cooling Return) C3Other(explain under#21 Remarks FROM TO DESCRIPTION color,haven solUroek type,grain ai etc.)
�} p ft. ) ft
4.Date Well(s)Complete ct -2-aL Well ID# 5� It- 610 G,' ft )9 to d, O
Sa.Well Location: ft, is ft �/C /Z c-'-
ft. J ft
Facility/Owner Name Facility ID#(if applicable) ft. ft
Physical Address,City,an
hyrem lip ft. ft ^1
C/� n�C L 21.REMARKS - UP-
t
County Parcel Identification No.(PIN) pesgll��
`��t10` S$CY10
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification-
. �
N W 7�J
6.Is(are)the well(s) Permanent or Temporary Signature if CertifiecrWell Cfsntractor Dale
,,,���(((_�-� By signing this form,I hereby certrfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and thou a
If this is a repair,fill out known well construction informatio and explain the nature ofthe 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: 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example- Q200''and 2@100) construction to the following:
10.Static water level below top of casing: 5— (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use r+- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: v (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
`n ( above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: f i% �)Z 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) 1 6 0 Method of test: t 24c.For Water Suyvly&Iniection Wells: In addition to sending the form to
the address(es) above, also submiil.one copy of this form within 30 days of
13b.Disinfection type: Amount: O Z completion of well construction to tiie 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
�. r_