GW1-2022-05302_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
Well Contractor Name FROM TO DESCRIPTION
2080-A 5 ft 6 ft. S—© 6
© Ft. 7/ ft. 5
NC Well Contractor Certification Number t v i
15:OUTER CASING for multi-cased wells)OR LINER ,f a livable
Aqua Drill, InG. FROM TO DIAMETER THICKNESS MATERIAL
Company Name /y ( i 't / 16.INNER CASING OR TUBING eothertud`closed-loo
2.Well Construction Permit#:� -y 3 �% fT 1L u�� FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well coustruction permits(i.e.UIC,Cour(v,State,Pariance,etc.) ft. fL In.
3.Well Use(check well use): h• ft in.
Water Supply Well: 17.SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMimicipal/Public ft. fL in.
Geothermal(Heating(Cooling Supply) 04S idential Water Supply(single) fL fL In.
-;Industrial/Commercial DResidential Water Supply(shared)
IS:GROUT
1rri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. O ft e �C
Monitoring. Recovery ft &
Injection Well: ft. fL
Aquifer Recharge [(Groundwater Remediation 19:SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
l Aquifer Test E3Stormwater Drainage fL fL
Experimental Technology I©_(Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20:DRILLING LOG attach additional sheets,if necessa )'
Geothelmal(Heati Cooling Return) I Other(ex lain under#21 Remarks) FROM TO DESCRIPTION color hardn soiVrack a rain siz eta)
9 _ r ft. fL -(
4.Date Well(s)Complete- I�-2—Well ID#6 Q+ I ft- t)Q ft sjq PJ cL C k
5a.Well Location: C!U ft 957 ft --01oc tZ
ft. ft
Facility/Owner Name L ) CFacility IDj#(ifapplicable) ft. ft.
ft ft
Physical Address,City,.and Zip ft. ft d ,
I G
G1!i) ( /- IZ- 21.REVARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/aduutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22.Certification:
6.Is(are)the well(s) ermanent or EDTemporary Signature of Certified Well Contractor 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: E]Yes or MNo with 15A NCAC 02C.010D or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and erplain the nature of the copy of this record has been provided to the well owner.
repair under 021 remarks section or an lire back ofthis farm. 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: u (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths il'different(example-3@200 and 2Qa 100� construction to the following:
10.Static water level below top of easing: 30 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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
J �-] l ) I above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 14r y G 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 276994636
13a.Yield(gpm) O Method of test: 24e-For Water Supply&Injection Wells: In addition to sending the form to
A the address(es) above, also submit one copy of this form within 30 days of
6 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 Wafer Resources Revised 2-22-2016