GW1-2022-01886_Well Construction - GW1_20220210

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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 DESCRIPTION
2080-A 62 ft ht PVI
ft. ft.NC Well Contractor Certification Number 15.OUTER CASING formulti cssediwells:OR;LINER.:ifsi 'livable
Aqua Drill, Inc. FROM TO DIAI�TER THICKNESSI MATERIAL
v' ft 0 ft. �/y ! in. -51 C/
Company Name
� r 16.INNER CASING OR;TUBING' eothermalclosed4oii i;
—0 C,
2.Well Construction Permit#21 . `�N H IZ"01(,S-2 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.
17.SCREEN
Water Supply Well: '
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
i Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. it in•'i
'lndustrial/Commercial E3Residential Water Supply(shared)
18.:GROUT
Irrl ation FROM TO!} MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ". V ft eem �--W+ U
Monitoring Recovery ft. ft.
Injection Well:MI --
ft. ft.
Aquifer Recharge Groundwater Remediation
'15.SAND/GRAVEL PACK '"7lcsble
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft. %
J Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) ®ITracer 20;DRILLING.LOG attach-addidonitl'sheets if:uecessa
Geothermal(Heatin Cooling Return) , Other lain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillroek type,grain size,etc.)
0 e. ft lZe-d 011 y
4.Date Well(s)Completed: �2?-ZZ Well ID# ft. it ;AAM KQ C r-
5a.Well Location: Laa
ft- 9 S' It. 1 c' GIzif 14 C!
ft. ft
Facility/Owner Name l— (- Facility ID#(if applicable) ft. It,
P ysical Address,City,an ip �� e^G ft. ft
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification:
i.'
N W t� �& — 7—.Z.Z
6.Is(are)the well(It6wrinanent or 13Temporary Signature of Certfied Well Contractor 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: [3Yes or 0
0 with 1 SA NCAC 02C.0100 or I5A 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 of this form.
23.Site diagram or additional well details:
S.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: G SUBMITTAL INSTRUCTIONS
r/ O 9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this 1form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: �0 (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
,A ` J�• above,also submit one copy of this form within 30 days of completion of well
i'i 12.Well construction method: Z- C 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) 0 Method of test: C'1,4 24c.For Water Supply&Iniection Wells: In addition to sending the form to
I' the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: q 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