GW1-2022-04838_Well Construction - GW1_20220520

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Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use only:
1.Well Contractor Information:
Chris King 14.NVATER.ZONES
Well Contractor Name FROM� TO DESCUPTION
2080-A el fL v i
NC Well Contractor Certification Number 20 ;221
15.OUTER CASING(for multi-cased wells):OR LINER(da cahle
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS " li MATERLAL
ft. ft in.
Company Name
0�ek,!V MANNER EASING OR TUBING( eothertnal'tloCKNES
2.Well Construction Permit#: � (� 1 FROM To DIAMETER TalctcNEss I nfATERTAi.
List all applicable well construction pe its(Le.UIC,County,State,Variance,etc.) ® ft, L C ft [�
/_d4
c
3.Well Use(check well use): ft, ft. in.
Water Supply Welk 17.SCREEN
PROM TO DIAMETER I SLOTSIZE THICKNESS I MATERIAL
Agricultural 1©IMunicipal/Public g, ft.
Geothermal(Heating/Cooling Supply) tgResidential Water Supply(single) ft. ft. in.
t3Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ;2 6 ft
Monitoring DRecovery It, ft. 7 r"
Injection Well:
Aquifer Recharge i[ Groundwater Remediation ft. ft
M.SAND/GRAVEL PACK(if a licablc
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) fQ1- Tracer 20.DRILLING LOG(attach additional sheets if necessa
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION color,bardaess,soi frock type,gmin sae,etc.
ft. T % v
4.Date Well(s)Completed:� Well ID# .D ft. ft
5a.Well Location: + [ ft 30 j ft J, uc e r-}•F
�"J JL 9! Gl�J� ft. ft
Facility/Owner Name Facility IM(if applicable) h• ft
521 ogzit,m 1 ��r��i�� ��- ,� ft ft
Physical Address,City,and Zip �y t ` rL %
✓L L_S 21.REMARKS NA V
County Parcel Identification No.(PIN) ® ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: l'• A�'14°1A^
(ifwell field,one lat/long is sufficient) 22.Certify Pion: - yhi
N VV
6.Is(are)the well(s)i6ermanent or rOTemporary 5rgnature of Cc ied l[CouhAtor Date
By signing thus form,I hereby certijy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or ONo with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out k»own we11 constr ction 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 ofwells construction details. You may also attach additional pages if necessary.
drilled:
'J' 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 ifdiQerent(example-3@200'and 2@/00� construction to the following:
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing Unit,
/fsvater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: /J (in.) } 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method _ /T �C J L f� y J above,also submit one copy of this form within 30 days of completion of well
.e.auger,rot '
(�r g wry,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: C 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 16 Method of test: S t �L� 24c.For Water Supply&Iniection'Wells: In addition to sending the form to
r� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: _L — Amount: Z completion of well construction to the county health department of the county
where constructed.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016