GW1-2021-01142_Well Construction - GW1_20210215

i
Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Bing 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A 6 JO-7 fL
ft ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-casedmells OR LINER if a 4cable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Q ft ft16 j in C 7 t/ L
Company Name V
�� 16:INNER CASING DR TUBING eothermal closed-loop)
2.Well Construction Permit#: / 2 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stat,Variance,etc.) ft ft. in.
3.Well Use(check well use):
ft+
ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft ft in.
:—)Geothermal(Heating/Cooling Supply) &Residential Water Supply(single) ft. ft. in.
j lndustrial/Commercial Residential Water Supply(shared) 18iGROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. j
1 Monitoring ORecovery ft. ft. r
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation <--�
;19:SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
—Aquifer Test ©IStormwater Drainage ft. ft.
Experimental Technology [I Subsidence Control ft. fL
Geothermal(Closed Loop) 1ITracer 20 DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,gmin size,etc
0 ft. ft \
4.Date Well(s)Completed:/--2 7-Z ll I We m# it,
S ft' 5 � OCt
Sa.Well Location:
ft. Z N
ft- ft Zo Gr
Facility/Owner Name Facility ID#(if applicable) -N 1 ft. ft W t G
/(? mWr , 3,z ft
Physical Address,City,and Zip - �y ft. ft.
Kow l� 6 0 Q,.0 7 2L REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) s 22.CertiP lion:
N p �br W 4 `
p + 7 a
r' tare of Certifie ell Contractor ate
( `
6.Is(are)the well( Prormanent or Tempoiar�''z ` %O'u ,,��
'J r�'ri ring this form,I hereby certiy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or lslo�� 'Ctvw'ith ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
,�, �— 1 co o this record has been provided to the well owner.
If this is a repair,fill out known well construction informati and explain the naturrk' Jhe,'.(jti copy f
repair under#21 remarks section or on the back of this form. ^'1 y_z'�,
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Welhaving Die 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: F- SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:7&/f -� (fL) 24a. For All Wells: Submit this,'form within 30 days of completion of well
For multiple wells list all depths if different(example/-3(�00'and 2Qa 100') construction to the following:
10.Static water level below top of casing: `col �j�_(ft) Division of Water Resources,Information Processing Unit,
If water 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 foam within 30 days of completion of well
12.Well construction method: q H IZ1 11 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
139.Yield(gpm) Method of test:- 1, 24c.For Water Supply&Infection 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: (D zi completion of well construction to Ithe county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016