GW1-2022-04735_Well Construction - GW1_20220510

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WELL CONSTRUCTION RECORD(GW-1) I For Internal Use Only:
1.Well Contractor Information:
Chris King d4.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A g- ft. 3I,6 ft. 3 G,): y1
k. ft
NC Well Contractor Certification Number f15.OUTER CASING.for multi cased'wells OR LINER if a`licable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS DATERIAL
Company Name ft. (/5 ft. in.
�O� I �I✓ /
�j ^� 16 INNER CASING OR'TUBING eothermal closed400
v 2.Well Construction Permit#: 2-[0 / FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) k. ft. In.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
3I Agricultural �MunicipaVPublic k. ft in.
Geothermal(Heating/Cooling Supply) ,Residential Water Supply(single) k. ft. in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O rt. Zd ft we \ ]�s
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19 SAND/GRAVEL PACK if s"livable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
PGcothermal
(HeatinConlin Return _Other(explain under#21 Remarks)
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) [3Traeer 20.DRILLING LOG attach additional sheets if necessary)
FROMI TO DESCRIPTION(color,hardness,soillmek type,grain size,etc.)
ft. ft !0 t'7 C i
4.Date Well(s)Completed: 3 -Zg— ell ID# 6 ft. yo 50 ft yv d /-0Q
5a.Well Location: V0 It. -965- it' 13&C 17 V 1'4 e
ft fL
Facility/Owner Name � Facility ID#(if applicable)
f. ft
ng—
q y M /2 C
k. ft. C: 0
Physical Address,City,and Zip ft. ft
21.REMARKS MAY 2no
County Parcel Identification No.(PIN)
�*r�� fi' g firm5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:N W Z
6.Is(are)the well( Permanent or Temporary Signature of Certified Well Contractor Date
pq( By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or N/ n with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
lfthis is a repair,fill out known well construction information land'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: J 9,• _ (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: C/y 00 Division of Water Resources,Information Processing Unit,
/fwater 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: /7/`/Z Lt/Z t 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
P
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13a.Yield(gpm) Method of test: S�YI 4- 24c.For Water Supply&Infection Wells: In addition to sending the form to
c the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 9 D 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