GW1-2022-03826_Well Construction - GW1_20220331

� Print;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 d,5- 6 ft- 36 61 P, M
k. ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased!wells ORLINER rf a licsblc
Aqua Drill, In FROM TO DIAMETER THICKNESS MATFRiAI.
® ft. ft. J� in. ➢Q It
Company Name
16.INNER CASING OR TUBING eother at closed-too
2.Well Construction Permit#: f U) FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,'Variance,etc.) k. ft in.
3.Well Use(check well use): k. ft
Water Supply Well: 17.SCREEN
FROM TO DIAMETER. SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public k. ft in.
Geothermal(Heating/Cooling Supply) nkesidential Water Supply(single) k_ ft. in.
Industrial/Commercial Residential Water Supply(shared)
18.:GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: V ft- .20 ft CeAn �rjW C
Monitoring Recovery ft. ft.
Injection Well: k. ft
Aquifer Recharge 13Groundwater Remediation
19 SAND/GRAVEL PACK'd:a""lica7ile
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control k. ft.
Geothermal(Closed Loop) ®ITracer 20.DRILLING LOG attach additionalsheets.if necessary)
FROM TO DESCRIPTION(color,hardness,sofll o k e, rain size,etc)
Geothermal(Heatin Coolin Return) +Other(explain under#21 Remarks a k. ft IZe
4.Date Well(s)Completed: 3—�LI—2-2—Well EN` k. ft. 5!r1
5a.Well Location: �rQT �� t 5 iVC CTrz)w Il�c
ft. ft
Facility/Owner Name Facility ID#(if applicable) k. ft
13 0 1 J I",, Iqc I ft. ft
Physical Address,City,and Zip ft ft _
J / I qf),air 21 REMARKS
County Parcel Identification No.(PIN) MAR 3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r
(if well field,one lat/long is sufficient) 22.Certification: ^'a
6.Is(are)the well(s) rmanent or Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes oro with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
ffthis 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 GeoprobetDPT 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: i SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / LJ (f-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (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: t4I'm d a t ' 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
e
13a.Yield(gpm) "30 Method of test: f C3 24c.For Water Supply&Iniection Wells: In addition to sending the form to
p the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: —7 Q -Z completion of well construction to! 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