GW1-2022-04625_Well Construction - GW1_20220510

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
2080-A ft. ? tt l
� r
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for malti-cased wells ORLINER ff a hcable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
p ft. _/ fG .y� in. U
Company Name
5f,
��'��^ '16:INNER CASING OR.TUBING eothei•mal closed-loo
2.Well Construction Permit#: / 2--2, FROM I TO DIAMETER THICKNESS MA
List all applicable well construction permits(i.e.UIC, ounty,State,Variance,etc.) ft. It
In.
3.Well Use(check well use): ft. I ft. in.
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) wResidential Water Supply(single) ft ft. in
Industrial/Comrnercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
lGeothermal
on-Water Supply Well: ® ft. ,o ft !v Nil �� - S
Monitoring Recovery ft. ft
jection Well:
ft. ft
Aquifer Recharge Groundwater Remediation
19.'SAND/GRAVEUYACK`if:a" li&bk)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft
Experimental Technology Subsidence Control h• ft
Geothermal(Closed Loop) [2Tracer 20.DRILLING LOG attach additional sheets if necessary)
(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soilfrock e, rain etc.
��99 0 ft. 6 It. ,�c d 0),41
4.Date Well(s)Completed:-Well ID# LA h' ft ONE K-Oe
5a.Well Location: ft. 0�ft lG �tdlvl`�C
ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft
�6R� ft. ft-
Physical Address,City,and Zip ft. ft
RECEIVED
21.REMARKS r(J
County Parcel Identification No.(P" MAY 10 2022
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i
(if well field,one lat/long is sufficient) 22.Certification: DW01210C,
N W
6.Is(are)the well(sPermanent or ®ITemporary Signature of Certified ell Co,*actor l Date
By signing this form,l hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or &0 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-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 ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 15r_0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service enter,Raleigh,NC 27699-1617
11.Borehole diameter: in.
(� ) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1 l`-� 1/ZZI I/ 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: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: S,t T 24c.For Water Supply&Injection Wells: In addition to sending the form to
/f q the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: `` Amount: I completion of well construction to the county health department of the county
where constructed.
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources' Revised 2-22-2016
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