GW1-2022-04941_Well Construction - GW1_20220516

Pr",'In tFolrrl w;,
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. G M
2oso-A lJ
k. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATE"R/
d ft. ft. in. 2)
Company Name
- }� 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: I (h (�f� 1'� ILL-)L FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): k. tt. in.
.17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE I TWCKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) aResidential Water Supply(single) ft. ft. in.
IndustriaUCommercial Residential Water Supply(shared) 18.GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. Q ft. T o c IC
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drhinage ft. ft.
NExperimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessa
Geothermal(Heating/Cooling Return) t Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiVrock type,grain size,etc
in ft. ft Z c
4.Date Weil(s)Completed: 7 L'-2�Well ID# k. -6 5' "" SA N RO 16
5a.Well Location: '9 S ft. _Rr it. Dlu C- 6zAvv I 4e
ft ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
S�y7� � 5 wrC gw� �izat,a ft. ft.
Physical Address,City,and Zip 5 tJ M;� W r k, ft.
J/?Cj i)J-_5 tZCl 21.REMARKS
County Parcel Identification No.(PIN) P
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: k1b Ur*(if well field,one lattlong is sufficient) 22.Certification:
MOMOG
N W 4- L2—
6.Is(are)the well(s) _ ermanent or Temporary Signature of Certified Well Contrac Date
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: [3Yes or 86N. with I SA NCAC 02C.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 of the copy of this record has been provided to the well owner.
l
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-I is needed. Indicate TOTAL NUMBER of wells 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 ifdifferent(example-3@2000'!',,and 2Q100� construction to the following:
10.Static water level below top of casing: (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 Iniection Wells: In addition to sending the form to the address in 24a
f 12.Well construction method: �� t �l above,also submit one copy of this form within 30 days of completion of well
� construction to the following:
(i.e.auger,rotary,cable,direct push,etc�� g:
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: q, 24c.For Water Supply&Iniection 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