GW1-2022-01143_Well Construction - GW1_20220103

.ri t Form
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 tt 0 !4r/
NC Well Contractor Certification Number 15.OUTER CASING Tor multi-eased wells)'OR LINER a llcable
Aqua Drill, Inc. FROM I TO DIAMETER THICKNESS MATERIAL
in. c
Company Name tv
I /�� x�i 16.:INNER:'CASING OR-:TUBING: g e&hermal dosed466
2.Well Construction Permit#: � I o(ir/��C/ 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. ft. in.
Water Supply Well: 17..SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in. j
Industrial/Commercial DResidential Water Supply(shared)
78:GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 40 ft
Monitoring Recovery ft. ft
Injection Well: ._ .
ft ft
r'sAquifer Recharge 13Groundwater Remediation
19.SAND/GRAVEL-PAC
K ifa 'licahle
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft
Experimental Technology Subsidence Control it. &
Geothermal(Closed Loop) Tracer 20.DRILLING:LOG attach additional sheets if necessa
Geothermal eatin C cling Return Other(explain under#21 Remarks FROM IP TO DESCRIPTION(color,hardness,soilfrock rain ' etc
/ k. ft
4.Date Well(s)Completed:/! — `� 1 Well 3 ft. 5— ft
ll ID S fJ ro d (56
5a.Well.Location: —ft t U c
.Lr r �.
r � s) lc� ft. ft I
Facility/Owner Name �� Facility ID#(if applicable) ft. ft. _
4/3 A� .s},e--Iz 2A 11;rtl s�yfi -S A(rm Ne
ft. ft 20 7
Physical Address,City,and Zip 2 710 7 ft. fL
r
21.REMARKS , " " wta x 1
ount 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 Signahue of Certified Well Contractor DatJ��e
6.Is(are)the well(s) ermanent or Temporary
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or&No 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 I 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: 3.2 (B-) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths if different(example-3000'and 2 100) construction to the following:
10.Static water level below top of casing: I'/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 Iniection Wells: In addition to sending the form to the address in 24a
,Q ' above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: r�[z 6z-1t 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)- v n Method of test: + 24c.For Water Supply&Iniection Wells: In addition to sending the form to
T the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: ! Amount: Za O 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
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