GW1-2022-10169_Well Construction - GW1_20221110

Print Form
WELL CONSTRUCTION RECORD(GW-� For[eternal Use Only: —tF
1.Well Contractor Information:
Chris King RF=r.R y r) 14,WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
2080-A NOV 1 0 2022 ft
rt
NC Well Contractor Certification Number It.
(wprtiww).1 Proca"W*UM 15.OUTER'CASING fo0 ft_r multi asedtiells OR LINER da licable '
Aqua Drill, Inc. Ci�NO/@rJG FROM ro ff
T1ICKNESS MATka
Company Name
16.INNER'CASING OR TUBING'(geothermal close&loo ,
2.Well Construction Permit#YG FROM TO D/M>ETER THICKNESS MATERIAL
List all applicable well construction permits fl-e.UIC,Cmmo,,State,Variance,etc.) ffi ft in
3.Well Use(check well use): tt. ft in.
Water Supply Well: 17.SCREEN
FROat TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural OMutncipal/Public tt tt. in.
Geothermal(Heating/Cooling Supply) Z idential Water Supply(single) R ft. in.
lndusftiaUCommercial DResidential Water Supply(shared)
1-1
iS:.GROUT
hri ation FROM I TO atATERML EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft
Monitoring Recovery ft, g
Injection Well:
Aquifer Recharge nGroundwater Remediation R. ft
Aquifer Storage and Recovery19.SAND/GRAVEL PACK if licabie
S8liaity Barrier FROM TO I MATERIAL, EMPLACEMENT METHOD
Aquifer Test 0StormwaterDrainage ft. ft
Experimental Technology oSubsidence Control ft. ft.
i I Geothermal(Closed Loop) (`)Tracer 20.DRILLiNGLOG attach additional sheets if necess
Geothermal eating/Cooling Return Other(explain under#21 Remarks FROM I TO DESCRIPTION color hardness,soNrock i7p a safe siz etc
ffi ft
4.Date Weil(s)Completed:) !r i a z Well ID# ft. ft 5 1-1) t ©C fi
5a.Well Location: E ft 5"'it l u e 6`-13 1 G
% ft.
Facility/Owner Name Facility IDp(if applicable) ft it.
ft ft-
Physical Address,City,and Zip �) ft ft
[ 2— cl 21.REMARKS
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Wong is sufficient) 22.Certify tlon:
6.Is(are)the well(sermanent or Temporary Signature of certified ell Con for Date J +
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: 0Yes oro with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this it a repair,fill out!blown well construction information and explain the nature of the 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 of wells construction details. You may also attach additional pages if necessary.
drilled:_
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (R-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple welts list all depths ifdii different(example-3 r@200'and 2Q100) construction to the following:
10.Static water level below top of casing: 5— (ft.) Division of Water Resources Information Processing Unit
If ureter level is above casing,use"+" + g ,
1617 Mail Service Center,Raleigh,NC 27699-1617
1 L Borehole diameter: (mJ) 24b.For In-ection ells: In addition to sending the form to the address in 24a
12-Well construction method: JA 1 LL C 17— j 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 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m `
(gP ) Method of test:� 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: Amonnk 2- completion of well construction to the county health department of the county
where constructed.
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016