GW1-2022-03006_Well Construction - GW1_20220228

Prir,I Form
WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A
ft. It- I �o r,
ft. ft.
NC Well Contractor Certification Number
154 OUTER CA
SING(for iulti-cased:vveus)
4;
; ML
Aqua Drill, Inc. FROM TO
DIAMETER TICK
S I MATERL41,
Company Name 0 ft. 175— ft
Kj in. 1.5p2;?l 1 .4 if ,C
:C Tc INNERASING OR-TUBING(jeotherinal doied400
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS :T MATERIAL
List all applicable well construction permits(i.e.FIC,County,State,Variance,etc.) ft* ft. In.
3.Well Use(check well use): ft. in.
ft+—
Water Supply Well: '17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:)Agricultural [31vitmicipal/Public ft. ft. in:
:.)Geothermal(Heating/Cooling Supply) Residential Water Supply(single) —ft. Ft - in.
3Industrial/Commercial (Residential Water Supply(shared) 1&GROUT
7 Im ation FROM TO MATERIAL' I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 9 6 It. . C
Monitoring Recovery ft. it
Injection Well: ft. ft.
Aquifer Recharge [3Groundwater Remediation
I m Monitoring
Injection
W n d
a t
It
Aquifer
19.SAND/GRAVEL if iiplilidhble)'�*,� M.
PACK
Aquifer
_T
quifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer
Aquifer Test C]Stormwater Drainage ft.
[Experimental Technology E3 Subsidence Control ft.
Geothermal(Closed Loop) Tracer 10;DRILLING.LOGfittach idditiodilsheits if nec6gaty)�',,;j:.
Geothermal
FROM TO DESCRIPTION(color,hardness,soil/mck type,grain shr,etc.)
eothermal(Heating/Cooling Return) Other(explain under#21 Remarks) C) to ". 17-cd Ifil V
4.Date Well(s)Completed:Z-5 -2,2.-Well ED# 10 7o It. lzocr,
5a.lell Location: It ft. It-
ZQ *
ft.
Facility/Owner Name Facility ID#(if applicable) ft. It.
2UTj L3 eJ)AcsJ1q 12d ft. ft.
EER 2 9 202Z
Physical Address,City,and Zip ft. ft.
REMARKS
5 4 o K P!�,- wo
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 C rtifi
N W
6.Is(are)the well(sApermanent or 13Temporary Signature of Certified Well Contractor Date
0 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 6o 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#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-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: 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: 5-0 (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
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 44"17- A l7a H 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 Ce"itter,Raleigh,NC 27699-1636
13a.Yield(gpm) O'd Method of test: li'all T 24c.For Water Supply&tniection 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: yr/-/ Amount: -z- completion of well construction to'I the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016