GW1-2022-05016_Well Construction - GW1_20220519

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
2080-A yv ft. ft 16 I
NC Well Contractor Certification Number . 6fL � ft j" 6 r .'7' wn'
15.OUTER CASING'for multi=eased wells OR LINER mf a livable
Aqua Drill, Inc. FROM I TO DLllviE'I'ER THICKNESS I1fATEtuAt
ft. ft Gn.
Company Name
! / 16.INNER CASING.OR TUBING 'eotherinal closed-loo
2.Well Construction Permit#: '
_' t/C� l Lit- FROM To DrnMETER T�CKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,letc.) ft. �3 ft � �i; 1n.
3.Well Use(check well use): ft. ft. in. u Y
Water Supply Well: 17.SCREEN -
_ FROM TO DIAMETER SLOT SIZE THICINESS L
Agricultural (OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT -
'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: -
� uj. 4C
Monitoring ORecovery ft. ft.
Injection Well:
Aquifer Recharge DGroundwater Remediation ft ft
19.SAND/GRAVERPACK if a livable
Aquifer Storage and Recovery OSalinityBanier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. fL
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if-necessa )
['ROM TO DESCRIPTION color,hardness,soiVroek •e, rain size,etc.
Geothermal(Hcating/Coolin Return) "_Other(explain under#21 Remarks)
0 ft. 5�1 fL I <f n I
4.Date Well(s)Completed-5 211, Well ID# fh fa )20 �CC
5a.Well Location: IS
5-ft.
ft. ft.
��
Facility/OwnetName Facility IDfl(ifapplicable) ft• ft.
�� ft. f A 2?
�61�1 nJ•-�-vtz;��v��c..Jt�.ri �rl��. f?�•� t. Lv 20
Physical Address,City,and Zip ( n.i�. 3 9 ft. ff
�141-41�r�� f3 21.REN ARKS
County Parcel Identification No.(PIN) {':i-:,.;7urriiv 3E"i:'� S:I�•.:�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lit/long is sufficient) 22.Certitic lion: /
N W
6.Is(are)the well(s)il/iDglitermanent or OTemporary Signature of Certified Well Contracto ate
By signing this form,I hereby certify that the wek(s)was(were)constructed in accordance
7.Is this a repair to an existing well: D Yes or 01
No with 15.4 NCAC 02C.0100 or 15A NCAC 62C.0200 Well Conshrtction Standards and that a
If this is a repair,fill out ltnown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 921 remarks section or on the back ofthis 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: �i SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: tS 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wets list all depths ifdierent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 570 (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: d s 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) Method of test: 1 G 24c.For Water Supply&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: 7 Amount:9 n 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