GW1-2021-00815_Well Construction - GW1_20210215

YPrnt Form,
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A ft g 01
ft ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells OR LINER if a licable
Aqua Drill, Inc. FROM TO DIAMETER
THICKNESS MA'rFRiAr. J
ft ft. 6// n. 5 v�7 � C.
Company Name `
16;INNER GASING:OR:TUBING eothermal closed-loo
2.Well Construction Permit#: �' _t JN 11 CZ—pl ec��J J FROM TO DIAMETER THICKNESS MATERWL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft ft in.
3.Well Use(check well use): ft ft tn•
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
u Agricultural OMunicipal/Public 0 ft ft in.
Geothermal(Heating/Cooling Supply)residential Water Supply(single) ft. ft. in
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-WaterSupplyWell: ft 2v rt dr✓irvl + Rucll
—'Monitoring ORecovery ft ft
Injection Well:
ft ft
Aquifer Recharge Groundwater Remediation
19:-SAND/GRAVEL'PACK(ifapplicable
Aquifer Storage and Recovery [ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test EJStormwater Drainage ft. ft
-:j Experimental Technology [Subsidence Control ft ft
3Geothermal(Closed Loop) ®ITracer 20.DRILLING LOG attach additional sheets if necessary)
i Geothermal(Heating/Cooling Return) a Other(explain under#21 RemarksLJ FROM TO DESCRIMON color,hardness,soivreck type,grain size,etc.
4.Date Well(s)Completed 2'✓ Well ID# &
5a.Well Location:
ft. 5-ft.
Facility/Owner Name ) r7 Facility ID#(if applicable) ft ft
6t�N-�►Z►�r K+S� � t�G� ft. ft
Ph icaI Address,City,and Zip ,r iv­r5 V�6\e 1 r 1C—��d s`I ft ft
2L REMARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if'well field,one lat/long is sufficient) 22.Certifieati
N W 01
6.Is(are)the well(s) ermanent or Temporary Signa of Certified Well ontractor Date ✓
��L��"```"'''"'' y signing this form,I hereby certify that the well(s)was(were)constructed in accordance
e, uh 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ©Yes or []No ,,�� . �,�����
If this is a repair,fill out known well construction information an.ez lbimertetof the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. r"°
11 � �OZ{ 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells h�v� helsa e 1 You may use the back of this page to provide additional well site details or well
construction,only l GW-1 is needed. Indicate TOTAL NUMBER of wells Alons�tppction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
c'.
� ` JJ
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: V (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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 Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /D Method of test: tr )l 24c.For Water Suably&Injection Wells: In addition to sending the form to
1 `I 0 Z the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 7 '�1) Amount: 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