GW1-2022-02875_Well Construction - GW1_20220228

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WELL CONSTRUCTION RECORD{GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name I—1 t .71 1t -30 61 Pt
2080-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi casediwells:OR LINER ffa livable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name ``11 e� /nODD` O ft. ft 61
in.
V tC
V I(/ /77 16.INNER CASING:OR TUBBING eothermal closed-loo
2.Well Construction Permit#: ,[ FROM TO DIAMETER I 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. fL in.
17.
IN,'
ater Supply Well: FROM E TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural �Municipal/Public ft. ft. in.
eothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in,
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
n-Water Supply Well: ft. ft.
t C ! �1 S
Monitoring ;Recovery ft. ft.
_ - jection Well: -__ - ft. it
Aquifer Recharge Groundwater Remediation
19 SAND/GRAVEL PACK if a licible
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD~
Aquifer Test [IStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heatin Coolie Return) ;Other lain under#21 Remarks) FROM 70 DESCRIPTION(color,berdaess soiVrock a rain s' etc
ft. ft. G
4.Date Well(s)Completed:2 Well ID# ft. �- f15A Ilk) 96 G L
5a.Well Location: S ft. Ql it.t' 31 U e iZ
ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ZI 11
1 ft. ft.
Ph sical Address,City,and Zip ft. ft FEB
_ V 1 J S a�S 21.REMARKS
d y
County 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:
ifN W -,/ �-
6.Is(are)the well(sRi'Permanent or ®ITemporary Signature of Certified 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: Yes or
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 ibis 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: / (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@200'and 2@100) construction to the following:
10.Static water level below top of casing: 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 Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: _ )'t 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)_ 30 Method of test: 24c.For Water Supply&Injection 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: 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