GW1-2022-04028_Well Construction - GW1_20220422

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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-A S ,5� - �6 Cyr! h�i
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR"LINER if a licable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. /5- ft- Z io. SDc'z.2C 1 V r C
Company Name c�
////��] ® .16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#:i 2 �O FROM TO DIAMETER THICKNESS 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 Munici al/Public t. in.
� � p fr. f
Geothermal(Heating/Cooling Supply) WResideritial Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 1s:GROUT
rInjection
tiOII FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ater Supply Well: ft. Q ft.
toring DRecovery ft. ft.Well: ft. - _ ft.
fer Recharge [3Groundwater Remediation
,19.SAND/GRAVEL PACK if a licable
3Aquifer Storage and Recovery E3 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
D,Aquifer Test O Stormwater Drainage ft. ft.
:Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) E)Tracer 20.DRILLING.LOG"attach additional sheets if necessary),.
- Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type rain size,etc
O ft. ft-
t Z e L/ d4oll
51
4.Date Well(s)Completed: 3 -.2 -2 2 Well ID# ft. 5-� ft.
r5a.Well Loca1titon:_ ' Q ft- Sft. �U� 7 /U �-�e
ft. ft.
G/ Facility/Owner Name Facility ID#(ifapplicable) f. ft.
ft.
M e4V Pm R Gy /�J &-1lI ( i
7i.
Physical Address,City,and Zip ft. ft.
y T h 21.REMARKS APR 22y
County T Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r
(i£well field,one latllong is sufficient) 22.Certification:
6.Is(are)the well(s) Permanent or I©ITemporary Signature of C6&ffled Well Contractor Date
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or allo with 15A NCAC 02C.0100 or 15.4 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 ofthis 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: 2 6 '�- 00 24a: For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
#'water 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
'� I above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:�A1J � �Z! I(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 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: Amount: 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