GW1-2022-06595_Well Construction - GW1_20220711

� ___ Prlrit Form
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 I Q fr fx �
NC Well Contractor Certification Number
15:'OUTER'CASING for multi�a d veelis:ORLINER a 'livable
Aqua Drill, Inc. FROM TO DIAMETER TDICErUS MATERIAL
Company Name fr. �9 %, m `
X16-HiNER'.CASING OR�TUBING(eothermal closed-loo :`.
2.Well Construction Permit#: �� tp�{'�Jad, FROM TO I DIA11fETER ' I THICKNFSS I MATERIAL
List all applicable well construction permits(i.e.UIC,Count)-,Sfate.Variance,etc.) ft. ft. j, in.
3.Well Use(check well use): ft. ft „ in.
Water Supply'Well 17.SCREEN'...,
..Agricultural OMunicipal/Public ft.FROM TO DIAMETER SLOT SIZE THiCKNRSS MATERIAL
'
Geothermal(Heating/Cooling Supply) Col Water Supply(single)
ft
IndustriaUCommercial []Residential Water Supply(shared) aBiGROUT.Irrigation FROM TO MATERIAL EMPLACEMENTrt.WrHOD&AMOUNT
Non-Water Supply Well: ft ft eem�NA OG r
Monitoring DRecovery fr. ft.
Injection Well: fr, it
Aquifer Recharge �_'�Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
Aquifer Storage and Recovery OSalinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft
( Experimental Technology OSubsidence Control it ft
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach'addiffoual sheets if necess
Geothermal(Heating(Cooling Return) rjOther(explain under#21 Remarks) EOM TO DESCRIPTION color,hardness,soilhock type,grain size,etc.
© ft ft �C
4.Date Well(s)Completed: IS/--,a-Well DD# 1\6 4- `-
,l
5a.WellLocation: 'fr
C4 djd ti
g
fG ft
Facility/Owner Name Facility 1D#(if applicable) ft ft.,3,7 Rcatycl 6-a- tAivcc�-Ie ��i q tt. >t P
Physical Address,City,and Ap fr. ft i
NrJCC 21.REMARKS,14
'County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal.degrees: .• ri:.., � ,i ,P���c
n
(if well field,one lat/long is sufficient) 22.Certitic •on: h i 2�g; ' t
N W 97 �c7
6.Is(are)the well(sermanent or Temporary Signature of Certified Well Contractor I Date
By signing this form,I hereby cent fy that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or/j§No with 1 SA NCAC 02C.0100 or I SA NCAC,02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction it formation and erplafn the nature of the copy ofthis record has been provided to the well owner.
repair under 921 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 of wells construction details. You may also attach additional pages ifnecessary.
drilled. SUBMITTAL INSTRUCTIONS
�d_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 lice all depths ifeli ferenl(example-3 20 and 2@1003 construction to the following:
10.Static water level below top of casing: G (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Cutler,Raleigh,NC 27699-1617
11.Borehole diameter. (m.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method:_ ;,41,1Z d above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct —z� construction to the following:
e. Push,eta) `
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: 1636 Mail.Service Center,Raleigh,NC 276994636
13a.Yield(gpm) J� Method of test: �l 24c.For Water Supply&Iuiecti In Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to Ithel county health department of the county
where constructed.
i
Farm GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016