GW1-2021-07522_Well Construction - GW1_20210903

4 `Print For
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. IL
t /
2080-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wefts OR LINER if a Gcable
Aqua Drill, Inc. FROM To DIAMETER TILICICNESS MATEIt1AI
® ft. ft. in.
Company Name
^� , Ce_ � I 76.1NNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: •t2©W k 1 n.n FROM TO DIAMETER TffiCKNESS MATERIAL.
List all applicable well construction permus(i.e.UIC,County,State,Variance,etc) ft. fL / e9 in. I i/
3.Well Use(check well use): ft. ft. too in.17.SC
/
Water Supply Well: FROMREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. In•'
Geothermal(Heating/Cooling Supply) krReIsidential Water Supply(single) g• ft. in..
Industrial/Commercial 13Residenfial Water Supply(shared) 18.GROUT
Iifi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. 0 fk
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge E3Groundwater Remediation
19:SAND/GRAVEL PACK!if a livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage B• ft.
Experimental Technology E3 Subsidence Control fL ft.-
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return Other lain under#21 Remarks FROM TO DESCRIPTION color,hardness,soilfrock type,grain s' etc
jD ft- q IL
C I
4.Date Well(s)Completed:� / � Well ID# L h 5— ft. lj J4Nd, Gic.
5a.Well Location: 5� ft* Sth �i V t
mQrZQA M ' ft. R.
Facility/Ownd Namie Facility ID#(if applicable) ft. ft.
1'-139 1,et_h110d,1 r- L.p J14j,uq P_ h. ft.
Physical Address,City,and Zip �j G ft. ft.W10, O�1
Z1:REMARKS
�� Processing
County Parcel Identification No.(PIN)
e
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: pWR
(if well field,one lat/Iong is sufficient) 22.Certification:
N W r �
6.Is(are)the well(s wrmanent or 13Temporary SVatore 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: [3Yes or ANo with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repay,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: ` SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 'D 0 J (ft-) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2Qa 100) construction to the following:
10.Static water level below top of casing: go (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
13a.Yield(gpm) 10 Method of test: i�G� 24c.For Water SunDly&Iniection Wells: In addition to sending the form to
�7 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 1 d O Z completion of well construction to the 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