GW1-2022-00148_Well Construction - GW1_20221219

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Chris King 14.-WATERZONES I
DESCRIPTIONWell Contractor Namc FROM TO DESCRIPTION
RO IL
�„` % � � �1 I
2080-A -1 "b
fL ft. l
NC Well Contractor Certification Number I'
15.OUTER CASING for mulUi cased tiells.OR LINER if a' licable
Aqua Drill, Inc. rROai TO DIAMETER THICKNESS MATERIAL
Company Name l�tL.0
IN rj 16. NER.CASINGORTUBING'(eotherntal closed400
2.Well Construction Permit#: / FROM TO DIAMETER THICIGMS MATERIAL
List all applicable well construction permits(i.e.UIC,Coutrh.Stata Variance,etc.) 8. ft In.
3.Well Use(check well use): M ft in.
Water Supply Well: 17.SCREEN' .:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Pnblic ft ft in
:-Geothermal(Heating/Cooling Supply) Residential Water Supply(single) M fL
htdustriaUCommeroial E31tesidential Water Supply(shared)
•.ls.GROUT'
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUI\T
Non-Water Supply Well: % .20
- Monitoring F3Recovery ft. ft.
Injection Well:
ft ft.
Aquifer Recharge OGrotmdwater Remediation
:19:SAND/GRAVEL-PACK da' licatile r
__ Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT PU7HOD
Aquifer Test OStorrawater Drainage ft ft ,
Experimental Technology )Subsidence Control S. ft
Geothermal(Closed Loop) OTiacer .20:DRILLING LOG attach additional sheets if necessa
Geothermal(Heating/Cooling Return) _Other(explain under#21 Remarks) FROM T/O'' DESCRIPTION color,hardness,soivmck a min size,eta
a ft (G ft i 'C
4.Date Well(s)Completed�2-s.� Well ID# ft. 5k�
:13s %g e�'5a.Well Location: s�ftlU
K(1-iU5�1 C' ft. rt. I'
Facility/Owner Name Facility ID#(if applicable) M ft
60 c-) m©i n FtA i-Lm r4-d 1. s aa� l f e ft ft '-- " r
L '':
Physical Address,City,and Zip iy t(' 27o 2 fL fL ' '_r r
2L REMARKS'
County Parcel Identification No.(PIN) °:- •-t1`, ^�� t
ric
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
U
_
(if well field,one Wong is sufficient) 22.Certifica'on:
N w "� Z
6.Is(are)the wells Permanent or Temporary Signature of Cc flid We Contractor 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: 10Yes orj2ffTo 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 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 ofthisform.
23.Site diagram or additional well details:
S.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: / gt� (fk) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2Q100) construction to the following:
r/� r
10.Static water level below top of casing: J. v (fQ Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 1617 Matt Service Center,Raleigh,NC 276994617
i
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
J r�` r above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: c: a l construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Celuter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test 24.For Water Supply&Iniection Webs: In addition to sending the form to
�} the address(es) above, also subnut one copy of this form within 30 days of
13b.Disinfection type: Amount: -i ©�- completion of well construction to the county health department of the county
where constructed.
Fomt GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016