GW1-2021-07542_Well Construction - GW1_20210903

WELL CONSTRUCTION RECORD(GW-1) IFRO
_mil Use Only:
1.Well Contractor Information: ' '
Chris King %TER ZONES
I TO DESCRIPTION
Well Contractor Name
$ 7ft• A 100
2080-A
ft
t
ft.
NC Well Contractor Certification Number 15. L+'IER.CASING for multi cased+wells OR L[NEE if Iteablc
Aqua Drill, Inc. FR R To DIAMETER THICKNESS MATERIAL
ft. ft in.
Company Name 16.INNER CASING OR TUBING` eothermai t[oseddoo _
2.Well Construction Permit#: FROM TO I DIAMETERI THICKNESSI MATERIAL
List all applicable well construction permits#.e.UIC,Coimn+,State,Variance,etc.) ft. fL In.
3.Well Use(check well use): ft. ft. In. I17.
Water Supply Well: FR ME TO DIAMETER SLOT SIZE THICKNESS MATERIAL '
Agricultural [3MunicipaUPublic R. & in.
Geothermal(Heating(Cooling Supply) Okesidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18:GROOT _
!Ini ation FROM TO MATERIAL EMPLACI M UN-17 METHOD&AMOUNT
Non-Water Supply Well, Ll ft. ? ft.
Monitoring 1311ecovery ft. &
Injection We":
it. ft.
I Aquifer Recharge E3Groundwater Remediation
19:SAND/GRAVEL PACK if a llcable._
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStomrwater Drainage ft. ft.
Experimental Technology Subsidence Control % fL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach addidonal'sheets ifnecessary)
Geothermal eatin Coolin Return) Other lain under#21 Remarks) FROM TO DESCRU'1'ION color,hardn soil/rack tym in e' eta
4.Date Well(s)Completed _q -z ► Well ID#
R.
Sa.Well Location: S v -C
ft. ft.
s.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
R. ft.
Physical Address,City,and
Zip ^ �2 ft. ft
21.REDiARKS
County Parcel Identification No.(P"
WOW. r aging Unit
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
3t�n. dIOT1
(if well field,one lat/long is sufficient) 22.Certification:
W %2
6.Is(are)the wells Permanent or a Temporary S to of Certified Well ntracto Date
O By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or)ETVo with 15A NCAC 01C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that
1f 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:
S.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: � 7 5 00 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dtfferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 5-0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
1.1.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
, �f3T� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: fZ i 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&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: ® 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