GW1-2021-03232_Well Construction - GW1_20210624

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WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Chris King
Well Contractor Name
2080-A
NC Well Contractor Certification Number
Aqua Drill, Inc.
Company Name 2. Well Construction Permit #: �`�; --
l�••l2
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural °Municipal/Public
Geothermal (Heating/Cooling Supply) lakesidential Water Supply (single)
Industrial/Commercial °Residential Water Supply (shared)
l Irrigation
Non -Water Supply Well:
Monitoring
Recovery
Injection Well:
Aquifer Recharge
iAquifer Storage and Recovery
f1 Aquifer Test
Experimental Technology
�i Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
°Groundwater Remediation
°Salinity Barrier
11 Stormwater Drainage
r Subsidence Control
°Tracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed: / Well ID#
5a. Well Location:
Facility/Ow
ner Name ^ Facility ID# (if applicable)
hysical Address tty, and Zip
�County't CS
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
6. Is(are) the well(s)
N W
ermanent or Temporary
7. Is this a repair to an existing well: ®Yes or o
If this is a repair, fill out known well construction informatio and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: .22
`
For multiple wells list all depths if different (example- 3@200' and 2@100)
10. Static water level below top of casing:
If water level is above casing, use "+"
11. Borehole diameter: '— (in.) 3
12. Well construction method: I fL d A £ r
(Le. auger, rotary, cable, direct push, etc.)
(ft.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) O Method of test: rJ tO 4
13b. Disinfection type: 0, Amount: F l0Z
For Internal Use Only:
14. WATER ZONES
FROM
TO
DESCRIPTION
l�oft.
ft.
16,S—ft-
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ;applicable) ._
FROM
CD ft.
TO
DIAMETER
THICKNESS l MATERIAL
Lt C' / ft 1 j5 in. SDiZst
I f V r c
AS1NG
ING (geothermal'"closed-loop):
OR
' 16 INNER C
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
:in.
ft.
ft.
in.
17. SCREEN
FROM
ft.
TO
ft.
DIAMETER
in..
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
18. GROUT
FROM
TO
MATERIAL':
EMPLACEMENT METHOD & AMOUNT
ft.
ego ft
ft
ft.
ft.
19. SAND/GRAVEL PACK{if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft
f.
ft.
20'DRILLING LOG (attach additional sheets ifnecessary)
FROM
© ft.
ft.
TO
If ft.
2152
S—ft
ft.
DESION (color, hardness, soil/rock type, main size, etc.)
BreAfocir
/9A)G
ft.
ft.
REC
V ED
ft.
ft
ft.
ft.
21. REMARKS
4 2021
JUN 2
procpssing Unit.
'11r toinlotron
DWR Section
ate
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with ISA NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
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
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
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
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