GW1-2022-06592_Well Construction - GW1_20220711

PrlritForm"�.;-
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: -- -
I
1.Well Contractor Information:
Chris King ,
14.WATERZONES
Well Contractor Name FR01L TO DESCRIPTION`
2080-A _ d ft' 7A) 'L / /'fit
ft. ft.
NC Well Contractor Certification Number
`.IS.OUTER'CASINGformulti=cased�wellsIOR-LINER'(ifa 'licable' '
Aqua Drill, Inc. FRODi TO Dlarorr rnR : THICKNESS M.TERIAL
Company Name yt^, ft �` in.
Qj�f��j ,�` ' 16.DINER CASING OR:TUBING" eothermaiclosed-loo
2.Well Construction Permit#: e(a /� FROM TO DIAMETER MATE
List all applicable well construction permits T.a UIC,County,State,Variance,etc.) ft. f6 in.
3.Well Use(check well use): tt fL in.
Water Supply Well: 47.:SCREEN
FROM TO'• DIAMETER SL
Agricultural DM OT SIZE THICKNESS MATERIAL .
tmicipal/Public ft ft
Geothermal(Heating(Cooling Supply) Residential Water Supply(single)
& S-
rndustrial/Commercial Residential Water Supply(shared)
18:'GROUT .`
i. :Itri ation FROM TO MATERGIL 'EMPLACEMENT MF•THOD&AMOIJ T
Non-Water Supply Well: fa ft
Monitoring i-Recovery ft, ft.
Injection Well:
i M ft.Aqurfer Recharge oG roundwaterRemediation
L_Aquifer Storage and Recovery '19i'SANDIGRAVELPACK if a'•licable ;;.
q g ry t�SalinityBarrier FRoni TO MATERIAL EnirLACEMENTbMMOD
_--Aquifer Test OStormwater Drainage ft
Experimental Technology OSubsidence Control IL ft
I
Geothermal(Closed Loop) Tracer
20_DRILf.ING LOGi attach additioual`sheets if neces
Geothermal(Heating/Cooling Return) n Other(explain under#21 Remarks) FRODi TQ I DESCRIPTION(color,hardness,sox/rock agrain slze6 eta
p �^( ft ft. • -
4.Date'Well(s)Completed X �—,2)— Weu ruff ? J ft. 56 ft 'j 1,PT cc�
5a.Well Location: It. ft-
Rt. ft.
Facility/Owner Name Facility lD#(ifapplicable) ft. ft
Physical Address,City,and kip % ft ,
f . .
1] :•21.'PVAARKS
County Parcel Identification No.(PIN)'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,t
(if well field,one latAong is sufficient) 2Z.Cerlifi lion:NZ W UN®fitI
P
l/ ^�
6.Is(are)the well
0161raument or OTemporary Signature ofCertifled Well CondacWr j, Date^
By stgning'h's farm,'hereby cerIO'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or To with 15A NCAC 02C.0100 or 15A MAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill old Imown well constntction Information and explain the nature ofthe copy of this record has beers provided to the well owner.
repair under#21 remarla•section or on the back of this form.
23.Site diagram or additional well'deiails:
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 INSTRIICTIONS
9.Total well depth below land surface: a 2
For multiple wells list all de ( ) 24a For All Wells: Submit this form within 30 days of completion of well
depths ifdifferent(example-3@2200'and 2@100) -.construction to the following: i
'w Static water level below top, casing: .J (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"/+' 1617 Mail Service Ce to;,Raleigh,NC 27699-1617
11.Borehole diameter: CJ (�,)
�//�� , JJ 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: /7 j �Z (`? ; ` above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mali Service Center,Raleigh,NC 27699-1636
� I
13a Yield(gpm) j Method of test: 24c.For Water SuDDIv&Iniecton Wells: In addition to sending the fort to
HTAZ the address(es) above, also submit{orie copy of this form within 30 days of
13b.Disinfection type: — Amount: © completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Envimnmentat Quality-Division of Water Resources Revised 2-22-2016