GW1-2022-03830_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
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells bR LINER.(if_a Iicable`-
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS M/ATERIAI
ft. LJ3 ft 6f2g, , in. ,C) �n4>�
Company Name
1 (� l C� ���! i6:INNER CASING'OR TUBING eothermal clICKN S -i
2.Well Construction Permit#: �'' FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Nblic ft. ft. in.
Geothermal(Heating/Cooling Supply) akesidential Water Supply(single) ft ft in.
�Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
M Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft
Monitoring ,Recovery ft. ft
Injection Well:
J Aquifer Recharge Groundwater Remediation 19SAND/GRAVEL PACK if a" licable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®I Stormwater Drainage ft. ft
Experimental Technology [)Subsidence Control ft ft
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heatin Cooling Return) ClOther(explain under#21 Remarks) D ft. ft C ,4/
FROM TO DESCRIPTION(color,hardness,willmek e, lain size,etc.)
4.Date Well(s)Completed: 3_J 5—�,2 Well EN 1,0� �� I S ft- 3S ft SA ati 120C K
5a.Well Location: 3S"ft- J9 ft j3�u G /Z�yt✓It
ft ft
-
Facility/Owner Name Facility ID#(if applicable) ft. ft. -
135rJ
Physical Address,City,and Zip ft. ft MAR 3 1 202'
'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 &/� :�/!//��
/7 — S— z Z
6.Is(are)the weil(s) Rermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or�1 b with 15A NCAC 01C.0100 or 15A NCAC 01C.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: 1 (ft-) 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 1@100) construction to the following:
10.Static water level below top of casing: (ftJ Division of Water Resources,Information Processing Unit,
Ifwater 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: f7'11 Z (:/Z 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) O Method of test: 6% 24c.For Water Supply&Infection Wells: In addition to sending the form to
q the address(es) above, also submit;one copy of this form within 30 days of
13b.Disinfection type: 11T- Amount: 1 d Z' completion of well construction to the county health department of the county
where constructed. i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016