GW1-2022-03177_Well Construction - GW1_20220307

'-Print Form ;
WELL _NSTRUCTION RECORD(GW-1)
For Internal Use Only:
1,Well Contractor Information: DEscR
14.WATERZONES,' IPTION
Chris King FROM TO 1
C�dft• � i ft o' 6-1 , rn
Well Contractor Name ft
ft.
2080_A a Iicable
15.OUTER CASING for.multi-cased;wens O, 11 rINEss MATFRrAL
IAa4ETE
NC Well Contractor Certification TO /D R
ification Number ft. t9 ��/ 1n. S V A Z I ! J t C
Aqua Drill, Inc. O
16.INNER CASING OR TUBING eothermalaEss MATERIAL
Company Name _ / y t' _�?/J73 FROM TO DER
ft. to
2.Well Construction Permit#:ermits(i.e.UIG Country,State,Variance,etc) in
List all applicable well construction p ft. ft.
3.Well Use(check well use): II.SCREEN D�ptvIETER SLOT SIZE THICKNESS MATERIAL 2
FROM TO is
Water Supply Well: ft. ft
Agricultural Municipal/Public
Geothermal(Heating/COoling Supply) esidential Water Supply(single) ft.
ft. 1O
'..1nd Geothermal
r mal(floating/ Residential Water supply(shared) 18..GROUT, TO - MATERIAL EMPLACEMENT METHOD&AMOUNT
FROM f. 1 /1 ft. Ct yl�nJ 4- /Z J
Irri lion O CJ
Non-Water Supply Well: ft, ft
Monitoring Recovery
ft. ft
Injection Well: if
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK'M�TE�n le ` EMPLACEMENT METHOD
Salinity Barrier FROM To
Aquifer Storage and Recovery ft. ft.
Aquifer Test oStornrwater Drainage ft ft
0subsidence Control
Experimental Technology 20.DRILLING LOG' attach DESCR PTIO eets'if necessa pn see etc)
Tracer FROM TO DESCRIPTION color,hardness,soillrock e,
Geothermal(Closed Loop) O ft. C `
eatin Coolie Return. Other(explain under#21 Remarks) / ft.
Geothermal(H (J
z 2 3 Z Z rt
4.Date Wells)Comp
leted: Well ID# - ft
ga.Well Location: ft, ft
n. ft.
Facility ID#(if applicable)
Facility/owner Name ft. fL
Ph ical Address,City,and Ztp L�l� 3(� 21:REMARKS'-
parcel Identification No.(PIN)
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: 2
'(if well field,one lat/bng is sufficient) 2,�2?) - •z
N r i Date
Signature Of Certified Well Contract ufr
6.Is(are)the well(sPermanent or Temporary
By signing this forrn,L hereby certify that the rveR(s)was(were)constructed in acco ante
'D with 15A NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
Yes or p), f provided to the well owner
-
7.Is this a"repair to an existing Nell:
co o this record has been
If this is a repair.fill out known well construction information and explain the nature ojthe 23.Site diagram or additional well details:
having You may use the back of this page to provide additional well site details Or well
repair under#21 remarks section or on rite back of this farm. also attach additional pages if necessary.
lls
8.For Geon,Only I GWo l Closed-Loop eeded. indicatee TOTAL NUMBS of wells construction details. You may
construction,only SUBMTfTAL INSTRUCTIONS
drilled: /) of completion of well
f— (ft.) 24a. For All Submit this form within 30 days
9.Total well depth below land surface: Ie 3 00 and 2@100� consnllction to the following:
For multiple wells list all depths if different(examp
3 0 (ft-) Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 1617 Mail Service Center,Raleigh,NC 27699-1617
If water level is above casing,use"+" addition to
(�) in 248
24b.For Iniection Wells: mof this form swihhin 30 ing d y of completionrm to the of well
11.Borehole diameter: ^ ' ' above,also submit one copy
`I construction to the following:
12.Wen construction method:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water'Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY: Of this form within 30 days c
24c For Water Su 1 &Injection Wells: In addition to sending the form b
O Method of test: the address(es) above, also submit one copy health department of the count
13a.Yield(gPm) Gi completion of well construction to the county
Amount: l where constructed.
13b.Disinfection type Revised 2 22-20'
North Carolina Department otEnvironmental Quality-Division of Water Resources