GW1-2022-01151_Well Construction - GW1_20220103

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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 DESCRIMON
2080-A
i oR /(2tL J
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for m!Lffl ased wens),OR L R d's ficable
Aqua Drill, Inc. FROM TO D=!E R THICKNESS MATERIAL
ft. tL A in. !11 , 6
Company Name 3 0� , l/
161NNER CASING'ORTUBING eothermal'd6iW466i '
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERr&L
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 R. ft. in.
Geothermal(Heating/Cooling Supply) Oktsidential Water Supply(single) fL ft.
Industrial/Commercial E3Residential Water Supply(shared)
lS.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. AO fL �_ % S
Monitoring Recovery fL ft.
Injection Well: R. fL
Aquifer Recharge Groundwater Remediation
19 s`SAND/GRAVEL PACK:if licable '
Aquifer Storage and Recovery E3Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage
Experimental Technology Subsidence Control R. fL
Geothermal(Closed Loop) Tracer 20;DRILLING LOG attach additionil sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock ty0e,grain size,etc.
Geothermal(Heatin Coohn Return) r3Other(explain under#21 Remarks) R. S ft.
4.Date Well(s)Completed Q '�I Well ID# R. fL AC
5a.Well Location: Q ` �R 2 C
O r\ • ��4\� S fL fL
Facility/Owner
wner Name Facility
Facility ID#(if applicable) R. fL
3 J 1 ) n � P\ , L(GK1.�C5 f1t9{1`t°.J R. fL
Physical Address,City,and Zip p � R• ft. r b
21rREMARKS - - -
County A Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ORR BERN
(if well field,one lattlong is sufficient) 22.Cerlific on: ,�� AATIC°�Fh'J':ESSIlJG UNI"
N W
6.Is(are)the weil(soiPermanent or 13Teroporary
Signature of Certified Well Con ctorGL7 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: ®Yes or D with I5A NCAC 01C.0100 or 1SA 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 ofthis 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surfacer (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@20tr and 2@100D construction to the following:
10.Static water level below top of casing: 160 00 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
� '�i / above,also submit one copy of this form within 30 days of completion of well
L 12.Well construction method: l I C..d o/ �r 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: 24c.For Water Supply&Iniection Wells: In addition to sending the form to
l the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 7 Amount: r2 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
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