GW1-2022-06902_Well Construction - GW1_20220718

WELL CONSTRUCTION RECORD(G"-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WAZER ZONES p '
E-ASLUMTER
' TO DESCRIPTION I I
Well Contractor Name ft. / fL f O t
2080-A fL (� ft. f 0
NC Well Contractor Certification Number ASING for iiidlti ased'ivells 0R13NER rf a livable
Aqua Drill, Inc. FROM TO DC4viETER THICKNESS MnTERIAr
/. ft: S ft. in
5 N i�1 1 U�a li
Company Name /� /�/(1 :I JNNERCASING"OR TUBING eotherinal'closedloo
2.Well Construction Permit#:, 5? .�2`•v 3 1 OM TO DIMiETEtt I TRICKNESS MATERIAL
List all applicable well construction pennrtss rLe I,County.State,Variance,etc.) ft. ft in.
ft. ft.
3.Well Use(check well use):
17.SCREEN. l
Water Supply Well: FROM TO DIAMETER SLOTS IZE TRICKNESS MATERIAL
Agricultural oMunicipal/Public ft. ft in. i
Geothermal(Heating/Cooling Supply)residential Water Supply(single) fL ft• in.
Industrial/Commercial oResidential Water Supply(shy) 18'GROUT _
Irrigation FROM TO MATERIAL. Eb1PLACEMENT BIETIIOD&AMOUNT
Non-Water Supply Well: tt ft. v
Monitoring Recovery ft. ft
Injection Well: fL' ft.
Aquifer Recharge oGmundwaterRemediation 19:SAND/GRAVELFACIC da hcablc!
Aquifer Storage and Recovery OSalinity Barrier FROM To MATERIAL 1TIPLACEMENT METHOD
Aquifer Test E15tormwater Drainage ft. fL
Experimental Technology 1ISubsidence Control
Geothermal(Closed Loop) OTracer 20.DRiLLINGLOG.attach additional sheets'irneccss '
FROM TO DESCR(FI(ON(color,dacdoess,soiUrock a rain siz etal
Geothermal(Heating/Cooling Return) _Other(explaiD under#21 Remarks) © ft. 5•- fL 9—C CA
4.Date Well(s)Completed: ` zWell ID# ft. S 3 ft. n J C, Q i
5a.Well Location: d ft lU Utr I e
ft. ft.
ivr
�FaF�ility/0 Name Facility ID#(if applicable) ft 6 v
ft. ft. 2022
�jQ —= l�t� �►I �- f�lrNS�iJA,/ -2�rr►^l ft. ft.
Physical Adfiesi,City,and Zip
©n� 21.REMARKS.
IL elY ~ siNG U I�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certifica n:
N W /J jv 7-.,
� Date
6.Is(are)the weil(s) rmanent or Temporary
Signature of Certified Well Contractor
By signing this form,I hereby certify that the weff(s)was(were)constructed in accordance
Standards and that
7.Is this a repair to an existing well: I0Yes or No with 15A'NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction
ffthis is a repair,fill out falown well construction information and erp/ain the nature of the copy ofthis 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 welljdetails:
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
constriction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled: y �( SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:, l U S (ff•) 24a.For All Wells: Submit this:form within 30 days of completion of well
For multiple wells list all depths'ifdifferent(example-33/@200'and 2@100) constriction to the following:
10.Static water level below top of casing: Ct� d (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: Cm•) 24b.For Iniection Wells: In addittol to sending the form to the address in 24a
above,also submit one copy of is form within 30 days of completion of well
/�
12.Well construction method: /'"^y A 1 Z i'L construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Infection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ' Method of test: C"tt/, 24c.For Water Sunni, &IniectionI 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:_A/r/A Amount: a 2 completion of well construction to the
e county health department of the county
where constructed. f
-Division of Watcr Resourc Revised 2-22-2016
Form GW-1 North Carolina Department of Environmental Quality ee
j, I