GW1-2021-00134_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 ft. 5— fa /00
ft. ft.
NC Well Contractor Certification Number 415.OUTER CASING for multi cased wells OR LINER da &cable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
tt. G5 fL /�in.
Company Name
'16:INNER CASING OR TUBING eotbermal closed-loo
2.Well Construction Permit#: /d�[O�e!�/✓✓ 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. tt. in.
17.SCREEN
Water Supply Well: i;
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. ft. in•
Geothermal(Heating/Cooling Supply) , $esidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fte s1 ft. 010 jZ O C
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge [3Groundwater Remediation
19.SAND/GRAVEL PACK"if aiipllciible '',
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD .•
_ Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLINGLOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness
Geothermal(Heatin Conlin Return) Other(explain under#21 Remarks) soil/racka is size eta
G © ft. g ft �C� �
4.Date Well(s)Completed: 3d -�/ Well ID#L� ` O# ft' it' 5 G(
5a.Well Location: ft, 2 S ft. '131e c [
ft. ft.
Facility/Owner Name /Facility ID#(if applicable) ft. ft.
m` lia 1 4,Ary C 4- V Pu C
ft. ft. D J r
Physical AddiJs,City,and Zip
ft. ft. O
ZVf/� l / lL REMARKS ?s
,e 4,/vcL�J
County Parcel Identification No.(PIN) /` d
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: / 7,
N W o !/JJ�/ -��
6.Is(are)the well(sPermanent or OTemporary Signature of Certified We 1 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: Oyes or oo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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 we construction details. You may also attach additional pages if necessary.
drilled: C SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / tJ (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: 20 (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
r J I above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: //Z (�/Z►/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)�U® Method of test: 5 I _ 24e.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: Z completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department o£Environmental Quality-Division of Water Resources Revised 2-22-2016
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