GW1-2021-00527_Well Construction - GW1_20211222

Tin Form
WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES,
FROM TO DESCRIPTION
Well Contractor Name
/— ft. � ft.
2080-A
ft. fL
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells OR'LINER If a Lcable
Aqua Drill, Inc. FROM To DIAMETER THICKNESS MATERIAL
ft. ft 6 % In. Z t(J •C
Company Name
r� // 16 INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: D 2-��J N 1"1 i 67 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. fL in.
3.Well Use(check well use): ft. fa in.
Water Su Well: 17.SCREEN
Supply FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Ji Residential Water Supply(single) ft. ft, in.
Industrial/Commercial Residential Water Supply(shared) r8.GROUT
Im ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft• ft. ecm.+ 1z r_
Monitoring 13Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19:'SAND/GRAVEL PACK if a "licatile
Aquifer Storage and Recovery Osalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology E3 Subsidence Control ft. fL
�Geothermal(Closed Loop) [3Tracer 20;DRILLING LOG attach,additiodatsheets if necessary)
Geothermal(Heating/Cooling Return) ;Other(explain under#21 Remarks) I
FROM TO DESCRIPTION color,hardness,soiLlrock type,grain size,etc
ft. ft- 1 C 1�
4.Date Well(s)Completed) Well ID# O ft. ft. 5 CL/ O IL
5a.Well Location: 7S ft, tt U G e
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. fL
rt..
Physical Address,City,and Zip /v
l xd 21 REMARKS —
22
unty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W Z)'-
6.ls(are)the well(s)�J4Permanent or Temporary rgnature of Certified Well Contractor Date
/o� 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: E3Yes 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 wells construction details. You may also attach additional pages if necessary.
drilled: �f SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /f� 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@10000D_ construction to the following:
10.Static water level below top of casing: cJ 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 Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: A/Z I ) 1 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 276994636
13a.Yield(gpm) Method of test: 1 C( h } 24c.For Water Supply&Injection Wells: In addition to sending the form to
1 O the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: FA 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