GW1-2021-07358_Well Construction - GW1_20210921

l ���. Print Form
WELL CONSTRUCTION RECORD(GW-1) � For Internal Use Only:
1.Well Contractor Information: ®�
Chris King „Nik 14.WATER ZONES
Well Contractor Name �4 Vn�` FROM �. TO fL DESCRIPTION
2080-A S� rig\r9
��0�e0\\
NC Well Contractor Certification Number k0\ eGY
4 \�3 �� 15.OUTER CASING for multi�ased wells OR'LINER ROD livable
Aqua Drill, Inc. \n`O �� FROM To DIAMETER THICKNESS MATERIAL
Company Name
ft. D It.
t / in.
16 1
O�C O�{ O 16.INNER CASING'OR Tt1BING eotherriial-doses-loo -
2.Well Construction Permit#: FROM TO 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. fL In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER 1 SLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. fL in.i
Geothermal(Heating/Cooling Supply) tesidential Water Supply(single) h, fL in.1
Industrial/Commercial Residential Water Supply(shared) I&GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. O fL C
Monitoring Recovery ft.- fL
Injection Well: _ _,
Aquifer Recharge Groundwater Remediation f L
19 SAND/GRAVEL PACK'if ii livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage R• fL
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary).
Geothermal ea' Coolin Return Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc
ft. fL
4.Date Well(&)Completed:2 1, l Well ID# L ft. S ft.
5a.Well Location: 1(5 fL 5�fL r "e Z f'
fL fL
Facility/Owner Name Facility ID#(if applicable) R' ft.
���L e a ro i'FC IZ l2-G� ft. fL
Physical Address,City,and Zip it. fL
4 21.REMARKS
County 10, Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat(long is sufficient) 22.Certtf cation-
� .�Z� 9
�( N W
6.Is(are)the well(s)j�Permanent or Temporary re of Certified Well Contractor Date
it���� �( 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: [3Yes or
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a --
Ifthis is a repair,fill out known well construction informatio�la4.d �xd plain the nature of the copy of this record has been provided to the well owner.
repair under#11 remarks section or on the back of thisform.
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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: ��jj SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5-e`1 (ft-) 24a. For All Wells: Submit this;form within 30 days of completion of well
For multiple wells list all depths if different(example-3(3a 200'and 2@100) construction to the following:
10.Static water level below top of easing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
,J above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: ./�/& &tz! I —- 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 A- 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: a•to 0 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