GW1-2021-07973_Well Construction - GW1_20211122

Int Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A
NC Well Contractor Certification Number M OUTER CASING for multi-cased:wells OIt LINER' :a 6cable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft, it ft. in- s��Z� I J
96.INNER CASING OR TUBING eothermal dosed 6 i
2.Well Construction Permit#: y FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): k. k in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public k. ft. in.
Geothermal(Heating/Cooling Supply) ,Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
I-ri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
k. ft- - S
Non-Water Supply Well: © o � G t
Monitoring Recovery ft. ft.
Injection Well:
k. ft.
Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEL"PACK ifs'licatile
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �Stormwater Drainage ft. ft
Experimental Technology [3Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.'DRILLING LOG attach additional sheets if necessary)
Geothermal eatin Conlin Return) Other(explain under#21 Remarks FROM TO DESCRHTION color,hardness,soiUrocktype, rain s' eta
fLI V,
fL
4.Date Well(s)Completed/ 'a Well ID# ft. ft. S81
5a.Well Location: C—ft' 15?5" 1Z 1CJ 1 L
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. fL
60010 kolua tel?)zv /2 Sl15hu/t'zy k- fL
Physical Address,Cit,and Zip IV-C 9�;'1 C1 C. fL ft
NOV 22
o,�/i I� 21.REMARKS
County C Parcel Identification No.(PIN) DWIP r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: INFORi!<ATinm Ppn FC
(if well field,one lat/long is sufficient) 22.Certification:
N W ! d /0 cZ /+1
6.Is(are)the weil(s),f Permanent or ®ITemporary Si re of Certified We ontractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or 4!fNo with 15A NCAC 01C.0100 or 15A NCAC 02C.0100 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: �j SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: D 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200 and 2@1001 construction to the following:
10.Static water level below top of casing: -! O (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: C (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
,f - ) above,also submit one copy of this,form within 30 days of completion of well
12.Well construction method: r/2. �:f2 f / / 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) t) Method of test: 14c.For Water Supply&Infection 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: —(: 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