GW1-2021-00129_Well Construction - GW1_20211213

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
2080-A ft. t
ft. ft
NC Well Contractor Certification Number ,15.OUTER CASING'formulti cased wells OR LINER,if a !!sable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESs MATERIAL
ft. 6 ft- in. D
Company Name i
�i^ ���,^ ` "'FROM ER CASING OR TUB AM eothermal d ICKN S
2.Well Construction Permit#: V t �+ 1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. �p s// in.
3.Well Use(check well use): ft. ft. 6 in.
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) &Residential Water Supply(single) ft. ft. in,
Industrial/Commercial _ Residential Water Supply(shared) I8 GROUT'
lrrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. IL a e&vo 1)
Monitoring pRecovery ft. ft.
Injection Well: ft. it
3Aquifer Recharge Groundwater Remediation
19 SAND/GRAVEL PACK:if i Iicatile
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. fL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additiooalsheets if necessary).
FROM TO DESCRIPTION color,hardness,soils o k e, rain size,etc.
Geothermal(Heatin Cooling Retum) Other(explain under#21 Remarks) y
4.Date Weil(s)Completed: Well>D# O f0 ft. 55 ft. 5 1U Id /2 — V✓t UC t
5a.Well Location: 5 ft -2 S
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft
0 lZ ft. �ft
Physical Address,City,and Zip ft. , t
A / 31.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.Certific don:
N W ` t s1
6.Is(are)the well(s) ermanent or Temporary Signature of Certified Well Co clot 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 o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out knoxm well construction information and ex lain the nature ofthe 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: �1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: SIC— 00 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: 2 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: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
e j above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: / /-2 C!%'Z t 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)Jam- Method of test: lY: 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:J61rli Amount: G ®� completion of well construction to the county health department of the county
where constructed.
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016