GW1-2022-03094_Well Construction - GW1_20220307

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Chris King 14.'WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ' r
rt. 3 ,t n,
� 7 rt. (s r M
2080-A
ft. fL
NC Well Contractor Certification Number 15.OUTER GASING for multi cased'we0s OR'L1NER'ife 'licsble
Aqua Drill, Inc. FROM TO DIAMETER TLIICIINESS MATERIAL h
/►� It. / ft. /� in.
Company Name 116.(INNER CASING OR TUBiNG(ebtherm slclosed-1o6
2.Well Construction Permit#:A 1 0 ���(�✓ 1 z- !10 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. tL in.
Water Supply Well: 14.SCREEN.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) h it in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT_
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 7 2
Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge 13Groundwater Remediation
19:-`SANDIGRA K,VELIPAC 'if:a""lieiitile y;3° 7 rx!P � ; a
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20a'DRILLING;LOG(attach aHditioriel sheetstf:necessa
Geothermal eatin Coolie Retum) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soil/rock grain size etc
_ I�1v �S�L 13 I v a �Z A A)% c
4.Date Well(s)Completed Well ID# ft. ft.
5a.Well Location: ft. ft.
rq S i I`� rt. ft
Facility/Owner ame Facility ID#(ifapplicable) ft. % j p0
ZOE
Physical Address,City,and Zip A ,t C' 9 7 3/ ft. ft.
t�u ; d�d i�i� ," 21.REMARKS : t
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:
N W
6.Is(are)the well(sloPermanent 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: Afyes or [3No with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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-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 ifdifferent(example-3(Q200'and 2@100) construction to the following:
10.Static water level below top of casing: ;z Q (ft.) Division of Water Resources,Information Processing Unit,
lfwater 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 illIis form within 30 days of completion of well
12.Well construction method: 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: e 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)_3 Method of test: J i 24c.For Water Supply&lnjection Wells: In addition to sending the form to
G the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: O a 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