GW1-2022-03827_Well Construction - GW1_20220331

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 ,Z D ft. )Z,)
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING form lti_!!ells)OR LINER If
licsble
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name D ft. .3 It- /5/0 in. t 0 9,? 1/o/)
����� 16 INNER CASING OR TUBING eothertnal closed-ES lM A
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. iL In.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Oi Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) IS GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMO[1NT
Non-Water Supply Well: b ft. rL c, C
Monitoring _ Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge E3Groundwater Remediation
19dSAND/GRAVEh'PACK`if4'"Iicable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft, ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20 DRILLING LOG attach additional sheets if necessa
11 Geothermal(Heating/Cooling Return) ,Other(explain under#21 Remarks) FROM TO DESCRIPTION(mloy hardness,willrock % rain size,etc.
.r^t ft. 5— ft &e—J
4.Date Well(s)Completed: 3 � Div ft' &, ft. ,5?q ria Iz d C K
5a.Well Location: S 75 ft 5' CIG c
ft. tL
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
136, A--ad'))tic: c i ft. ft.
Physic/al Address,City,and Zip ft. ft.
/ /y!/�l✓G P. 21.REMARKS
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: MAR
(if well field,one lat/long is sufficient) 22.Certification:
N W
6.Is are the wells ermanent or []Temporary Signature of Certified Well Con i .. Date
F�JIs(are) () E mP r Y
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: DYes or O(No 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-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-3 000'and 2@100D construction to the following:
10.Static water level below top of casing: J 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: CJ (in.) 24b.For Iniection 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: l`�Z (1 1 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
h
13a.Yield(gpm) 20 Method of test 24c.For Water Suooly&Iniection Wells: In addition to sending the form to
d the address(es) above, also submit[one copy of this form within 30 days of
13b.Disinfection type: r Amount: 1 8 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