GW1-2022-04730_Well Construction - GW1_20220510

Print Form
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 R/
k. It.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licable
Aqua Drill, Inc. FROM TO DIAMETER THICKQNEQSS MATERIAL/
n.
FROM ft. TO f t DIAMETERier t o ed to /"�1L1
Company Name
` >76.INNER CASING OR TUBING" eothermalclosed-loo
2.Well Construction Permit#: b 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.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public k. ft in•
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft in.
1 Industrial/Commercial DResidential Water Supply(shared)
- 18.GROUT
i lrri ation FROM ... TO MATERIAL EMPLAC MENT METHOD&AMOUNT
r
Non-Water Supply Well: a ft, ft. CA
Monitoring Recovery ft. ft
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL'PACK'if applicable)
'
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG'attach additional sheets if necessary)
Geothermal(Heating/Cooling CooliII Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock a rain etc.
k' /� ft c�
e"a k. c y ft 4 j9
4.Date Weil(s)Completed:��eil ID# �lJ T � � r �/7W
5a.Well Location: ft. t fUC
ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft P
r�¢O�6L— /^n ! dJ_ _/1,� _ _ / ft. ft 5
Physical Address,City,andJZiipjl'F✓��e / k• fL 4
a 21.REMARKS
D fv^Ct+fng Utlk'
IC County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:_
644;
z
6.Is(are)the well(s) ermanent or Temporary Signature of Certified Well ontracto 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: ®Yes oNo 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 an 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: 32 S'— (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifeli erent(example-3@2200'and 1@100D construction to the following:
10.Static water level below top of casing: J� (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 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: //Z /2
l 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) J Method of test: :!5 � 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:/'2 Q 2- 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