GW1-2021-07957_Well Construction - GW1_20210809

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Chris King 14.WATER ZONES
TO DESCRIPTION
Well Contractor Name FROM
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2080-A
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NC Well Contractor Certification Number 15 OUTER CASING formWti cased'we s`ORLINER 1f a Gcable
Aqua Drill, Inc. FROM TO DIAIYD2TEi THICKNESS MprRRIAr.
Company Name
ft. fP%ft ` in. 5Q 2 z I/c
AA �1 �16 INNER'CASING ORTUBING. eothermal-closed-loo -' '-
2.Well Construction Permit#: 2�g I el Q n 0 12 c— , 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.
17.SC
Water Supply Well: FROM REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in•
Industrial/Commercial 131tesidential Water Supply(shared) 18i GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. (� ft. G'
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if a 1lcable '
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology E3 Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.'DRILLINGLOG attach additional sheets.if necessary)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc
ft- fL e/
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4.Date Well(s)Completed: Well ID# le ft' ct
Q�-ft S � D
5a.Well Location: ft ; J t' Z + G
ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft
F _ ft. ft. @�
hysical Address,City,and Zip e 5 1R V etc)
h c)e-o /.,V f ft' fft. .�
21.REMARKS " y"
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:
N W t
6.Is(are)the well(s) Permanent 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: [3Yes or�No 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 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: 02(� (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@200'and 2@100) construction to the following:
10.Static water level below top of casing: g© (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
C above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: z- \ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) f
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: 15 tgA Ja+ 24c.For Water Supply&Iniection 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: Amotmt:� 0 2 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