GW1-2021-00469_Well Construction - GW1_20211222

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 v Q
ft. rL
NC Well Contractor Certification Number 15.OUTER CASING for multi cased'wells OR LINER if a 'livable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. It ���j in. /�
Company Name
;��y ,��e A� i 16.INNER CASING OR TUBING(geothermal dosed-ES
2.Well Construction Permit#: n(� FROM TO DIAMETER THICKNESS MA7'F'RrAt.
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. fL in.
3.Well Use(check well use): ft. R. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft, ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
Industrial/Commercial [IResidential Water Supply(shared)
18.GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. % / S
Monitoring Recovery ft. ft. t
Injection Well:
Aquifer Recharge Groundwater Remediation ft. IL
19:SAND/GRAVEL PACK if a Hcable -
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT-METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology 1ISubsidence Control fL %
Geothermal(Closed Loop) Tracer X DRILLING LOG,(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ' Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soilfrock type, rain size,etc.)
ft. ft.
4.Date Well(s)Completed. -z Well ID# d �? rt• -] l`L $ ruId Aoe/C
5a.Well Location: ft. S fL lU'G- k11
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
)�N��—� /2RhVgo N ft. ft.
PhQysical�^Address,City, Zi,an d p ft. ft.+— p-E c 2 —2 ?
! l,g�/Y Xt 21:REMARKS
Couunty� Parcel Identification No.(PIN) �z
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/iong is sufficient) 22.Certiticati
N W 4 ) _ 2 -, J
6.Is(are)the well(s ermanent or Temporary g:at. of Certified 11 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 jNo with 15A NCAC 01C.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#11 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (t-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@20 and 2@100) construction to the following:
10.Static water level below top of casing: O (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: C (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
�i�Z G (/mil, / / above,also submit one copy of this!form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Uliderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) J Method of test: 5 �'i PV+ 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: Amount: (D 0 Z completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016