GW1-2022-05255_Well Construction - GW1_20220526

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only.
1.Well Contractor Information:
Chris King 14.WATER ZONES.
FROM TO DESCRfPTION
• Well Contractor Name 6 R, / tL -
Zoso-A .261t. 12 ft C) i
NC Well Contractor Certification Number 15.,OUTER CASING(for muld-crised',wells.O LINERA 2pplivable
Aqua Drill, Inc. FROM TO DIAME TMCICNF.SS MATE
RIAL
0 ft 2 7 ft. 6 in.
Company Name �/ (� 16.INNER CASINGORTUBING. eothertnaldosed-loo
2.Well Construction Perm �Fit#: ✓� J t—J�-n I��j FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits Cl.e.UIC,County,State,Variance,etc.)
fL ft. is
CL ft
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DAMETER SLOT SIZE TEiICKNESS MATERIAL
Agricultural DMunicipal/Public ft fL in,
Geothermal(Heating/Cooling Supply)residential Water Supply(single) ft. fL in.
Industrial/Commercial DResidential Water Supply(shared) 18;GROUT
+..lrri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It. �V fL
Monitoring DRecovery ft. ft.
in We14 ft. %
Aquifer Recharge DGroundwater Remediation
�} 19.SANDIGRAVEL.PACK if a livable,
Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACE v¢NT METHOD
Aquifer Test 0Stormwater Drainage ft• ft
Experimental Technology OSubsidence Control ft, ft
Geothermal(Closed Loop) (Q-ITracer 20.DRILLING LOG fattach.additional sheets if necessary)
Geothermal eating/Cooling Return) i Other(explain under#21 Remarks) FROMTO DESC1lIPTlON color,hardness soiVroek a rain size eta
CL ft
4.Date Well(s)Completed: 5 r{ 2well ID# b � 1- d, 5-fL • . o C
5a.Well Location:
% ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. fL iq rd
Physical Address,City,and Zip �� C ft ft 7
f J 21.REMARKS
county Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wellfield,one lattlong is sufficient) 22.Certification:
N W
6.Is(afe)the well(s)6ermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or 6§4NO with'15A NCAC 02C.0100 or 15A NCAC 02C.0200 weft Construction Standards and that a
If this is a repair,fill out/aeown well construction information and explain the nature of tyre 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 ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I 1 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
ror multiple wells list all depths ifdifferent(example-3 a(�l 00'and 2@100) construction to the following:
10.Static water level below top of casing: C) (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
{7 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: /� ' construction to the following:
41
(i.e.auger,rotary,cable,direct push,eta)
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 Supply&Injectiou 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: O 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