GW1-2021-01063_Well Construction - GW1_20210322

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
PROM TO DESCRIPTION
Well Contractor Name
2080-A
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING !or maltibsad weHa OR LINER ifa ble
Aqua Drill, Inc. t OM TO DIAME ER THICKNESS MA'1"F.RIAI.
Company Name d fL It G iro wrzaf 1 I C
F �} rl a 3 16.INNER CASING OR TUBING thermal closed-too
2.Well Construction Permit N: e mom TO I DIAMETER THICKNESS MATERIAL
I w all appbmbl,well canvrunion permit'(l.e. UI(',Coumv..Srme.4"miance,etc? ft ft t
3.Well Use(check well use): f. ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZF. THICKNESS MATERIAL
Agricultural Municipal/Public 0 ft, ft la.
Geothermal(Heating/Cooling Supply) ` ,esidential Water Supply(Single) ft• ft in.
Industrial/Commercial [)Residential Water Supply(shared) I&GROUT
IRI ffitOn FROM TO MATERIAL EMPLACEMENT MMIOD&AMOUNT
Non-Water Supply Well IT. R. �` �
Monitoring Recovery ft. ft
Injection Well:
ft. ft.
Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa ble
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ❑Stormwater Drainage H. n•
Experimental Technology ❑Subsidence Control R ft.
Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG am addith ml sheets ifvecema
FROM TO DE5CRIPr1ON akio 6acdnw,notltmck ize,etc.
Geothermal(Heating/Coohng Return) Other(explain under#21 Remarks) O ft ft �, 1
/ IYA
4.Date Well(s)Completedv''JJL -�2i( WellID# 14 ft. '7j ft
�S/a'.�W'ell Location: �zAryl3.3 H. D. A
Facility/Owner�Name �eV/-1 Facility 104 ri-applicable) f. ft
7 0 /—lYpe•1f�Snl" /ZL f. ft. q..
Physical Addmss.City.old Zip f. ft p r
21.REMARKS
County FAA ys�)7 Parcel Idemification No.(PIN)
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latdong is sufficient) 22.Certificati
6.Is(are)the well(sPermanent or ❑Temporary Signature of Cenified Well Contractor Date
U,,.occur,on,Jorm I hereby cent that the a-ells)was/were) mas ruvred Ia acenrdan,e
7.Is this a repair to an existing well: ❑Yes or.,EfNo with 1,A N('A( 01('.0I(10 or 15A N('A('02(' 0200 We//('omernonma Standards and thus a
Jfthm is o renon,fill ant known well oororuasea is ranwom and,-Juan the nature aJMe toper of this record hav heen pmvlded ro the well owner.
repair under H2/remarks section or on the back ofthaform.
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 I GW-I 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: �Q S Ht-) 24a. For All Wells: Submit this form within 30 days of completion of well
Purmuluplew,11,Irvialldepths,fdifferent(erample-3200'and2u)100') construction to the following
-
10.Static water level below top of casing: Go (ft) Division of Water Resources,Information Processing Unit,
if.,,,level i.'oboe,coda,,use "-" 1617 Mail Service Center,Raleigh,INC 27699-1617
11.Borehole diameter: K7 (in.) 24K For IDiection Wells: In addition to sending the form to the address in 24a
''''�� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: I 0J? 1 I construction to the following:
(i.e.eager,rotary,cable,direct push,etc
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY W//�EE/L�JLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 5�+ 24c For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
I36.Disinfection type: ��/ Amount: completion of well construction to the county health department of the county
where constructed.
F.,G W-1 North Carolina Department of Environmental Quality,-Division of Water Resources Revised 2-22-2016