GW1-2022-03841_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
ft.
k. ft.
NC Well Contractor Certification Number 15.OUTER CASING for muiti-cased wells OR LINER if a licable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name ® It. 77 ft. c/ in. I�5 )12, ' l 1/1 c
�r 16.INNER CASING OR TUBING(geothermal closed-loop) v
2.Well Construction Permit#:.2 �_V ( `�i�t1 fZ-O®3�1_7 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): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public k. ft. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) fL ft. in.
Industrial/Commercial [)Residential Water Supply(shared) 18.GROUT
nj Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. % l�r-1101
_Monitoring Recovery k. ft. Ix
Injection Well:
k. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK](if ao 7icatile
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage k. ft.
Experimental Technology LL 1 Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/CoolingRetum) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiVrock a rain size,etc
ry� k. fL e I
4.Date Well(s)Completed:2_�00— �Well ID# / ft. 6 5 rt 5 A wd Izz0 C C
5a.Well Location: ` k. 57fL V C S Z I
ft. ft.
Facility/Owner Name Facility ID#(if applicable) k. rL
7?73 9MtC hisr_ 5 S i e�-2eerishn ow rJ aC k. ft
Physical Address,City,and Zip e Z-�(-'SS It. ft.
REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
N W
E
6.Is(are)the well(s) Permanent or 131remporary 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 fid_No with 15A NCAC 02C.0100 or I5A 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-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 if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 (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
/t I� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: A C. ! 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: 11__ LL 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) � Method of test: l G't r\T 24c.For Water Supply&Iniection 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: F1Amount: 1 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
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