GW1-2022-04143_Well Construction - GW1_20220425

4Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well COntrdetOI Name FROM TO DESCRIPTION
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 TfficICNEss 11tATF61, 6
R/iAr.r
Company Name O ft. G'O ft. '� in. 5 t1)Z Z V r 6
r� (� '16 INNER CASING OR TUBING(geothermal closed-loop
2.Well Construction Permit#: _ c•JG FROM TO I DIAMETER THICKNESS DATERIAL
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.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Pubhc ft. ft. in.
Geothermal(Ileating/Cooling Supply) CafRdsidential Water Supply(single) ft. ft.
Industrial/Commercial nResidential Water Supply(shared) 18.GROUT
Irtl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. ft. &UhuiA, �h
Monitoring - DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
i 19.SAND/GRAVEL PACK if a licable_
Aquifer Storage and Recovery [DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary):,
- Fc.)
Geothermal(Heating/Cooling Return) _ Other(explain under#21 Remarks) FROM
TO DESCRIPTION(color,hardness,soil/rock type,grain size,et
fL fL 0/
�/_ ✓ ft. t tt
4.Date Well(s)Completed:�Well ID# � '.S s� U zQ
�5a.Well Location: �Q e y S It- 70 5ft. ig f J ' 1
ft. IL
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
I a n 5�,�!Z4 Lao soniu 12 v-) , z ft. ft.
Physical Address,City,and Zip ft. fL
21.REMARKS
County Parcel Identification No.(PIN) ARR
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat(long is sufficient) 22.Certification (•.,.:
N W
6.Is(are)the well(s) Permanent or DTemporary
Signature of Certified Well Contractor Date'
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: nYes or/!!�No 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 ofthis 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: 2067 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifelifferent(example-33@@200'and 2@100D construction to the following:
10.Static water level below top of casing: (O (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
,Z ,--1 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 9! k/IZI construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY
/WELLS ONLY: C 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) Method of test: J 24c.For Water Supply&Injection 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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016