GW1-2022-10699_Well Construction - GW1_20221205

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only: I
1.Well Contractor Information:
Chris King 14.WATER ZONES i
Well Contractor Name FROM TO DESCRIPTION!
% 4 ft `9
2080-A 6, '
ft. ft
NC Well Contractor Certification Number t5 OUTER.CASING for.inultitased.wells ORLIN&R rfa licable
Aqua Drill, Inc. FROM TO g DIAMETER THICKNESS i MATERIAL
Company Name 0 ft 86 ft. ? � in. 5 1221 .4� V.S.V
�j�,�y� C 16:-INNER'CASINGiOR•TIIBING. "eo2hermai closed-1ao -
2.Well Construction Permit#:,/(' ! J FROM TO DIA!M=R i T►HcxivESS MATERIAL
List all applicable well corutnrctio ermits(i.e.UIC,County,State,Trarlatim etc.) fL fL iO
3.Well Use(check well use): R' ft in,
Water Supply Well: 17.SCREEN.
pp y FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
AgriculturalMtmicipaUPublic ft ft in
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft g,
1ndustiial(Commercial DResidendal Water Supply(shared) 18::GROUT
Irrigation FROM TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft
Monitoring. Recovery % ft
Injection Well: ft ft
:-)Aquifer Recharge nGroundwaterRemediation
19.SAND/GRAVEL PACK rfa llcable
Aquifer Storage and Recovery OSalinityBanrier FROM TO MATERIAL; EMPLACEMENTMETHOD
3. Aquifer Test OStormwaterDrainage % &
ExpetimentalTechnology OSubsidence Control D- M
Geothermal(Closed Loop) E3Tracer 20.DRILLiNG LOG'attach additioual•sheets if neeessa'
_Geothermal(Heating/Cooling Return) F30ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sotVrock type,grain sire,etc
d IL ft 56 1
4.Date Well(s)Completed-/ '— G Well M# ft ft k,
Sa.WellLocation: eft . !ftBloc! •tf izrW')A
i ����� SAS• _ fL
fL
Facility/O erName Facility lD#(if applicable) M fL _ s n a n ,,
C .'l'i rC ft ft ��`L ��,�C' V CZL
Physical Address,City,and Zip ft ft.
/ 21-REMARKS.
County ParcelIdentificationNo.(PIN) ;- 'fir ^''sic' llkU
„J_
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certification:
6 l �
if W-zz
6.Is(are)the wells)iORermanent or OTemporary Sigoaturu of Certified WellContiacOr 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 No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction.Standards and that a
If this is a repair,fill out known well construction biformation and explain the nature of the ropy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of thisform.
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: (ti-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdifferent(example-3Qa 200'and 2Q100) construction to the following:
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10.Static water level below top of casing: (ft.)) Division of Water Resources,Information Processing Unit,
IJwater 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 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: l 1 Z I ! construction to the following
(i.e.auger,.-tary.cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) Method of test i 24c.For Water Suuoly&Injectioo 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: Amount: 45-2— 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 Water Resources, Revised 2-22-2016