GW1-2022-02898_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 DESCRH'TION
WellConaactorName 2080-A rt.
�I.7tIv�Il
k. fL
NC Well Contractor Certification Number 45.OUTER CASING`formutti cased wells OR.LINER if:a )feeble
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERU►/L
Company Name ft. 11. G�L in. u/L Z
16.INNER CASING OR TUBING ebthermal dosed-loop)
2.Well Construction Permit#: -005-/ 's, FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UI ,County,State,Variance,etc.) k, ft. In.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Mtmicipal/Public k. ft. in.
Geothermal(Heating/Cooling Supply) Sesidential
esidential Water Supply(single) fL fL in.
i IndustriaUCommercial Water Supply(shared) 18.GROUT
Ili) ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 12 0 ft. no rlI 72 oc3
Monitoring Recovery ft. fa
Injection Well:
_ k. ft.
Aquifer Recharge [3Groundwater Remediation
19.SAND/GRAVEL'PACK'If'e"licable
Aquifer Storage and Recovery E2Salinity Barrier FROM To I MATERIAL TEMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology E3Subsidence Control ft. fL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG:attach additional sheets;if.necessa
FROM TO DESCRIPTION(color,hardness,soil/rock VM grain size,etc.)
Geothermal (Heating/Cooling Retum 00ther(explain under#21 Remarks) J
k. fL U (a i<A '/ J
4.Date Well(s)Completed: "Z-�� Well EW ft. " tL 5 AJd KOC ` M.V C%
5a.Well Location: ft' t � Z [ e
_` _ ft. ft.
�Q r P✓� P,ttaP�
facility/Owner Name Facility ID#(if/applicablle) ft. fL
r aon t�1 Cl i�fl l'. I✓ ft. ft
Physical Address,City,and Zip .27
3 f^� fL fL
t /u;l d Fa l - t7 31:REMARKS MC
DWORWO
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:
6.Is(are)the well(s)6ermanent or ®ITemporary Signatures ofCertified 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 No with 1 SA 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 an 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: t— SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: t�0 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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
,/ I above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: /!/�/ /Z [![Z 1 � 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 276994636
I
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
AA the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:�— Amount: V Z completion of well construction to the county health department of the county
where constructed.
Form GW-t North Carolina Department of Environmental Quality-Division of Water Resources 4 Revised 2-22-2016