GW1-2022-01208_Well Construction - GW1_20220103

Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIMON6C � It- _
2080-A '
57
k. ft.
Well Contractor Certification Number 15.:OUTER CASING for multi cased;wells:ORLINER if;a licsble
Aqua Drill, Inc. FROM TO DIAMETER THICIQYESS MATERIAL
J
Company Name Q ft S�ft_ / / In. 5 f2 4k I `•' t G
/ "16.INNER CASING OR TUBING(geothermal elosed400
2.Well Construction Permit#: �r I GI FROM To I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,ConV 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 J3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft, ft. in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
_,Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Welt: ft. �_O ft.
Monitoring Recovery ft. ft. -
Injection Well: t
ft. ft.
Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEL PACK if a i`licable
Aquifer Storage and Recovery Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control f, ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/mck type,gmin size,etc.
ft. fL d (t
4.Date Well(s)Completed:/ 7 4 1 Well iD# sp ri d O c K,
5a.Well Location: (�ft. it 1 t)C I' L L
ft. ft. 'I
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Ph • 1 Address City,an Zip
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
f well field,one lat/lon sufficient
(i g•is ) 22.Certification:
6.Is(are)the well(slf[J�1'ermanent or Temporary Signature of Certified Well ontractor ate
t(((���--�" 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 E!fA[o 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#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 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 (t) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi$erent(example-3@200cand 22@@j100) construction to the following:
10.Static water level below top of casing: J `/ (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: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
2 1 ) above,also submit one copy of this form within 30 days of completion of well
(L12.Well construction method: /` ,f I I construction to the following:
(i.e.auger,rotary,cable,direct push,etc..))
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY 'ELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test:�Q 24c.For Water Suoaly&Iniectionl 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: l 0 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