GW1-2021-00529_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14i WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A
ft. tt
NC Well Contractor Certification Number 35rOUTER CASING for multi cased wells OR LINER ifa 6cable
Aqua Drill, Inc. FROM TO DIAMETER TIHCKNESS MATERIAL
ft. So it- G /�' in. S�n2) t v , G
Company Name
Q� .INNER CASING OR-TUBING eothermal closed-loo ;
2.Well Construction Permit#:a) l^&)N}j7z -08))5- FROM I TO I 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. ft. in.
Water Supply Well: -17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
:]Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply)45tesidential Water Supply(single) IL ft. in•
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 20 it. C4nft-)Jr- /'Z Ot;�
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge 13Groundwater Remediation _
19 SAND/GRAVEL•PACK(Tapplivable
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
PExperimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Gcotherinal eatin C ohng Return Other(explain under#21 Remarks) I FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc
�1 1 ll ID D ft. ft
4.Date Weil(s)Completed:/ et We # 0 � 01 ft' fL (V GI JJ00C
5a.Well Location: �U� (S)Z t9IV 1'4 C-
ft. ft
Facility/Owner Name Facility 1D#(ifapplicable) ft. ft
'2?V7 Cga5Glti Pii4K %
Physical Address,City,and Zip rV
77
�TC/1-�//�o IZe z1:REMARKS
County Parcel Identification No.(PIN) O�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(if well field,one lat/long is sufficient) 22.Certification:
N W 1,2 - 7-,2I
6.Is(are)the well(s) Permanent or Temporary Signature ofC ontra r 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• FlYes or No with 1 SA 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 ojthis record has been provided to the well owner.
repair under#21 remarks section or on the back ojthis 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: U (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifeli ferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 30 (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: 24b.For Infection Wells: In addition to sending the form to the address in 24a
�)•`� n above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: cam+`1 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) O Method of test: 5` t 24c.For Water Supply&Injection Wells: In addition to sending the form to
Q the address(es) above, also submit]one copy of this form within 30 days of
13b.Disinfection type: � Amount: [ completion of well construction to the county health department of the county
where constructed.
Form GW-L North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016