GW1-2022-03003_Well Construction - GW1_20220228

Prin Form
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 S ft. Szl ft.
ft. ft
NC Well Contractor Certification Number A5.OUTER CASING for could-cased wells ORI:INER ifa livable
Aqua Drill, Inc. FR TO DIAMETER THICKNESS MATE-i .
ft. V 6 ft in. !�0 7 R 2-( I(/t C
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#:�r!�/ I O 7 0 f FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,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 ft. ft. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) tt ft. in.
's Industrial/Commercial Residential Water Supply(shard) 18.GROUT
Ilri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. O it Ci�Nf� t `s
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
_Aquifer Recharge Groundwater Remediation
19 SAND/GRAVEL PACK if i'liei ble r<z l
Aquifer Storage and Recovery EISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft, fa
Experimental Technology OSubsidencc Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if.oecessa
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiBmck a grain size,etc.
® ft. ft. /Z c J4 C1
4.Date Well(s)Completed: -IC) '� 11well EN Z rt. � b ft 54 w d
5a.Well Location: t kic t
ft ft.
Facility/Owner Name /� 7 J /�,� ,FFacility ID#(if applicable) ft• ft
^���/ r Y l�i.t 3—�L r' I\L trt .5L)
1 I 1 ft. tt
0C/ 732 o ft. ft nq,o� plea Unk
Physical Address,City,and Zip
�/, i n 21.REMARKS P
�Cf�tab ��
County Parcel Identification No.(PIN) {!,
i,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22�Z7
N W 2 -/ V —�z
6.Is(are)the well(s)oermanent or 13Temporary 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 J No with 15A NCAC 02C.0100 or ISA 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 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-I 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 ifdifferent(example-3Q200'and 2Q100D construction to the following:
10.Static water level below top of casing: 416 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
' 1 1 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: /f t-�I t / l construction to the following:
(i.e.gdger,rotary,cable,direct push,etc.)
i. � Division of Water Resources,!Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: I g r1 24c.For Water Supply&Infection Wells: In addition to sending the form to
J the address(es) above, also submit:one copy of this form within 30 days of
13b.Disinfection type: �7 Amount: Z completion of well construction too 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