GW1-2021-07595_Well Construction - GW1_20210903

nPrint�Form
WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A 7P- 2 76 ft S-o
ft. %
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft' Y "" I t1,
Company Name
/ `16:INNER CASING OR TUBING eotbermal closed-loop)
2.Well Construction Permit#: In 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 in•
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft, ft, in.
lndustrial/Commercial Residential Water Supply(shared) 18.GROUT
In7 ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. O ft -36- ru
Monitoring DRecovery ft. ft.
Injection Well: ft. ft
%Aquifer Recharge 13Grotmdwater Remediation
19.SAND/GRAVELPACK ifapplicable)
'
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. It.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal eatin Coolin Return Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soilfrock type,gMii s' etc
O ft. ft
4.Date Well(s)Completed: 7730 Well ID# 3
It- �-c�fL J z Q<
J 5a.Welt Location: ft' � fn 1310 a 6r 12
!�aefllity_/Owner Name 7 / /e Facility,ID)#(if applicable) ft ft O
4O G A /r ®Dr1 �± e:- mg ti4oftj ru r ft. ft
Physical Ad s,City,and Zip 7017 Q
5� b re S 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification`: j� h
6.Is(are)the wells)oPermanent 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: 13Yes or ZNo 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 I GW-I 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: 42 E S (ft-) 24a. For Ali Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'aand 2@I00) construction to the following:
10.Static water level below top of casing: '2 `' (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
/ !Z. 2 I 1 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: 1- 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) J 0 Method of test: S tU Ln T 24c.For Water Supply&Iniection Wells: In addition to sending the form to
f the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: '6 /r 14 Amount:J _ completion of well construction toi 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