GW1-2022-04731_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
f
2080-A fr. L 5 (� t
fr. fL
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased!wells OR LINER if a ticable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. CJ 3 ft. � in. I /O%y
Company Name
!/ [� ,o � `16:1NNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#: 7� 7 �C�L FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UI ,County,State,Variance,etc.)
3.Well Use(check well use): fr• ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural oMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
Industrial/Commercial E311esidential Water Supply(shared) 18.GROUT
Ifrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. O ft. �
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
3 Aquifer Recharge ®IGroundwater Remediation
19.SAND/GRAVEL PACK'1f applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [IStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other a lain under#21 Remarks) FROM TO DESCRIPTION color,hardness soiVrock a rain size,etc)
-- D fr, ft. e d
4.Date Weil(s)Completed: Z Well ID# ft. It. t f U
5a.Well Location: fr. ft.
Lot- ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. 4
r'4 �CL�IZ mot!S ��� ft. ft.
ft. fL
Physical Address,City,and Zip
tq1i#1 a mr 21.REMARKS � g." L L.... A R1:
County Parcel Identification No.(PIN) �' t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certitiea' n:
N W • _2-_Zz
6.Is(are)the well(s) Rermanent or Temporary 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: 13Yes or JNo with 15A NCAC 01C.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 ofthe 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: 3 P-VC (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi./jerent(example-3(,20�0'and 2Qa 100') construction to the following:
10.Static water level below top of casing: tJ ® (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 Iniectlon 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: 491 /Z.i 1 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: 24c.For Water SuoDly&Infection 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: Z— 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