GW1-2022-03095_Well Construction - GW1_20220307

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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 2080-A it t 1 P1 !1n
ft. fL /�
NC Well Contractor Certification Number 15.OUTER CASING for'multi cased wells'URLINER if a licable
Aqua Drill, Inc. FROM TO D1AIVIETER THICKNESS MATERIAL
7 ft. ft. I in.
Company Name
"'16.INNER CASING:OR_TUBING.' eethermsl'elosed400 :
2.Well Construction Permit#:2 l C�o — _,Z HR '0 G D�l(, 1-1
2 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. <46 ft. In. I(! r G
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT S17E THICKNESS MATERIAL.
Agricultural 13Municipal/Public k. ft. in.
Geothermal(Heating/Cooling Supply) f2fPtesidetial Water Supply(single) ft. ft.
Industria/Commercial E2Residential Water Supply(shared) 18.GROUT
'1ni ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 7 ft. ? ft. p
Monitoring Recovery 0 h C-/0 IL onh eA. I O u 17-- 1 i N C/,1—
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
i9 SAND/GRAVEL+PACK:if-a-"licatile "
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) ®ITracer 20.DRILLINGLOG,attachkildiddriiii A6ets':ifnecesse"'
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock e, in size,etc.
,t. I Slut 28 A
4.Date Well(s)Completed: 2 -.2-2well ID# ft• it
5a.Well Location: ft. tt•
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. fL
g020 �u4hL11'CL'J Pri- ��'erv5oizo ,N 2022
Physical Address,City,and Zin ft. ft.
C 21.REMARKS
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 &4,_
6.Is(are)the well(s)11[�Yermanent or Temporary Signature of Certified Well Contractol j Date
'.PPS, i
By signing this form,I hereby certify that the rvell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: es or [3No with 15A NCAC 01C.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: S V� 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Qa 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 lniection Wells: In addition to sending the form to the address in 24a
/�
t?J/ / above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: tq 1 x 21 I l 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 27699-1636/13a.Yield(gpm) y O Method of test: S t Ct I 24,For Water SuDDIv&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: 7 Amount:1l0 0 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