GW1-2022-03832_Well Construction - GW1_20220331

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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-A125-
ft. ft. 3 y/>I M
ft. ft
NC Well Contractor Certification Number 'A5.OUTER CASING for multi-eased wells OR LINER.ifa licable z
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
6 ft / It 6 5/p In. , (�gg �-
Company Name '16:'INNER CtAS®ING OR'TUBING tgiothermal closed-loop)
I/
2.Well Construction Permit#: —/�� vW lip h FROM TO DIAMETER THICKNESS MAT ERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. it. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: "17.,SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:]Agricultural E3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
18t GROUT
—I Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: C ft. a ft
Monitoring Recovery ft. ft
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a licabte
Aquifer Storage and Recovery Salinity 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 necessary)
Geothermal(Heating/Cooling Return) E]Other(explain under#21 Remarks) I
FROM TO I DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
�( // ft. tt
4.Date Well(s)Completed: �/ tell ID# t0 !p ft. 5 IL Po
/{ �'7�U �G C y
5a.Well Location: ft. C �t 151be 7 T e
ft. ft
Facility/Owner Name �j Facility ID#(if applicable) ft. It
1lrJ 95 l C17�Z�� /Ig\ t'+� ft. ft
Physical Address,City,and Zip ft. ft
21.REMARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
MAR 31 202
(if well field,one lat/long is sufficient) 22.Certification:
N W `j J 3— ' 2
6.Is(are)the well(s)o'ermanent or Temporary Signature ofCertffied VTell Contractor I Date
� 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: [3Yes or Elko with 15A NCAC 02C.0100 or 15A NCAC 02C.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: I) CL (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'annd 22@100) construction to the following:
10.Static water level below top of casing: (ft.) 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 Iniection Wells: In addition to sending the form to the address in 24a
r above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1 '� t" `Pj�� 1 construction to the following:
(Le.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) .30 Method of test: 5tci
24c.For Water Supply&Iniection 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:-ATAmount: —z► completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016