GW1-2021-00130_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
Well Contractor Name FROM TO DESCRIPTION
2080-A S ft. IK, !rt -0 t
ft. ft.
NC Well Contractor Certification Number I5OUTER CASING formulti cased wells ORhINER ifa livable`'
Aqua Drill, Inc. ''FnRROM TO DIAMETER THICKNESS MATERIAL
Company Name V ft `13 ft S� in. o { $ � _ /
cam/ /� / 16.INNER CASING OR TUBING eothermat closed-loo C/
2.Well Construction Permit#: o 4i�6(.C/�k ri Z FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. f4 In.
3.Well Use(check well use): ft. ft. in.
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
'ilAgricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) AaResidential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Ilrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. zo fI e 9 nArT f
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEI'PACK if.a liable
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft. ft.
Experimental Technology E3 Subsidence Control ft. M
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) rlOther(exylain under#21 Remarks) FROM To DESCRIPTION color,hardness,soil/rock type,grain size,etc.
& C
4.Date Well(s)Completed:i _�� "z, Well ID# IUT C 16 -
5a.Well Location: It ft U C 4:77zd Yaf L-
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
vl ft ft
Physical Address,City,and Zip ft. ft.
YYI p Y� 31:REMARKS 1
County Parcel Identification No.(PIN)
t ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: r a "' `' t 1
N w
6.Is(are)the well(s) Fermanent or Temporary Signature ofCertifi d Well Contractor 11 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: ®Yes or MNo 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: I �"� 1) (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2Q100D construction to the following:
10.Static water level below top of casing: (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
JJ above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: �t-rZ C IZ1 �� construction to the following:
(Le.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) Method of test: 5 I[ 24c.For Water Supply&Iniection Wells: In addition to sending the form to
66 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:AER Amount: Q 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