GW1-2021-03230_Well Construction - GW1_20210624

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased!wells'OR LINER if a licable'
Aqua Drill, Inc. FROM TO DIAMETER' I TRICKINESS MATERIAL.
Company Name 6 Ili iR. 101 V
t i f- G'
C�^ 16 INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: C1 FROM TO DIAMETER THICKNESS MATERIAL.List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) k. I 1n.
3.Well Use(check well use): k. ft. in.
Water Supply Well: 17.,SCREEN
FROM TO DIAMETER SLOT SIZE TRICKNESS MATERIAL
Agricultural ®IMunicipal/Public k. ft
Geothermal(Heating/Cooling Supply) wsidential Water Supply(single) ft. ft.
Industrial/Commercial 13Residential Water Supply(shared) 18.GROUT
IIti ation FROM TO MATERIAL :EMPLACEMENT METHOD&AMOUNT
lGeothermal
-Water Supply Well: ft. Q ftonitoring Recovery k. ft.
ction Well: ft. ft.
quifer Recharge Groundwater Remediationt9:SAND/GRAYELPACK ifa ticableuifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
uifer Test �Stormwater Drainageft. ftperimental Technology Subsidence Control k, ft.
othermal(Closed Loop) Tracer 20.DRILLING LOG attach addition at sheets if:necessa(Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,sontrock type,grain size,eta
in fl. ft e
4.Date Well(s)Completed Well ID# ft. Q`Gft. / U(j K fld r,
r
5a.Well Location: k
FL ft
Facility/Owner Name t
j� Facility ID#(if applicable) k. f
6Lz0n3CL k. ft
Physical Address,City,and Zip ft ft
C 4 0 re 21 REMARKS I ..fj i.'<
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W
6.Is(are)the well( ermanent or Temporary Signature of Certified Well 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: 13Yes oVo 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 of this form. 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 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: _(ft•) 24a. For Ail Wells: Submit this j form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example- 00'and 2Q100) construction to the following:
10.Static water level below top of casing:�© (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: (in.) 24b.For Iniection 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: t C�j construction to the following: p
(i.e.auger,rotary,cable,direct push,etc.)
f I'
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Celpnter,Raleigh,NC 276994636
13a.Yield(gpm) Method of test: `00t 24c.For Water Sunaly&Iniection Wells: In addition to sending the form to
/ the,address(es) above, also submit one copy of this form within 30 days of
*>7 13b.Disinfection type: Amount: ! ® completion of well construction to;the county health department of the county
where constructed. E
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016