GW1-2022-03833_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 U k. ;171 rL Q '
k. k.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if:a Heable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name �C
V ft. (� ft. / /g in. ,Q�
V l�"
( ��( 16.INNER CASING OR TUBING eothermal closed400
2.Well Construction Permit#: `I o ty)tf L� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) k. fL in.
3.Well Use(check well use): ft. ft- in.
Water Supply Well: 17.;SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:')Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
_ 1ndustrial/Commercial Res
idential Water Supply(shared)) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. It.
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL=PACK'if a licahle'
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology D Subsidence Control ft. fe
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/mck typN grainsize etc.
1 O ft. It-
t e
4.Date Well(s)Completed:Well ID# a l' L) )d ft. 2 Cf ft. 91CCA/
5a.Well Location: It. e 1
A. ft.
Facility/Owner Name Facility ID#(if applicable) ft. It.
)3SS ����c c � ft. ft.
Physical Address,City,and Zip k. IL
'jn)A L� "I-A Y r,le 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: J
(if well field,one lat/long is sufficient) 22.Certification
N W ;Vl - -2— Z
6.Is(are)the well(s) manent or ®ITemporary Signature of Certified Well Contractor 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: ®Yes or &o 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 1 GW-I 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: 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example--33@200'and 2@100) construction to the following:
10.Static water level below top of casing: Lo v (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 Iniection Wells: In addition to sending the form to the address in 24a
,/l l'� ��� l above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: ! 7 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: a 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test• J 24c.For Water Supply&Injection Wells: In addition to sending the form to
//aa�� the address(es) above, also submit`one copy of this form within 30 days of
13b.Disinfection type: Amount: Of ©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