GW1-2021-07983_Well Construction - GW1_20211122

Print Form; :-
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
2080-A 3T&- 3.5-i ft I T6- 1 it
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for U&I 011 LINE&If a Heable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL -
Company Name ft. ft - � ,m- S P17 J71 V J
16.INNER CASING OR TUBING(geothermal cllbseii-loopl
2.Well Construction Permit#: (Cj FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. C,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 MunicipaUPublic R, ft. in.
Geothermal(Heating/Cooling Supply) • Residential Water Supply(single)
ft ft in.
lndustrial/Commercial IDResidential Water Supply(shared)
1R GROUT .
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. I
Monitoring Recovery ft.
Injection Weil: ft. ft. '
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVELPACK if a licable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control It ft
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary).
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM I TO DESCRIPTION(color,hardness,soillrock a grain size,etc.
ft. ft Z f - v
4.Date Well(s)Completed:l f -z ) Well ID# 6 R• ))v ft SAAAJ r—p vllucf
5a.Well Location: J16
ft. -ft. W
yvik
ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft. P P
2 5^7 Q N C <6 - n )+y Y , C ft. ft. -
.JAIiyJ•� LU
Physical Address,City,and Zip r� ft. ft
4 u < U c? 21.REMARKS
ION
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certifiea'on: C/
N WAO!2
6.Is(are)the well(s) ermanent or OTemporary Signa re ofCertified 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 ONO with 15A NCAC 02C.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 wider#21 remarks section or on the back of thisform. 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
2
9.Total well depth below land surface: J 9 S— (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@2200'and 2@1001 construction to the following:
10.Static water level below top of casing: y (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.) t. 24b.For Injection Wells: in addition to sending the form to the address in 24a
J/� Z � r 1 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: ; / G ( t 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) o 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: TU Amount: 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