GW1-2021-03459_Well Construction - GW1_20210607

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIMON
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NC Well Contractor Certification Number 15,OUTER CASING for maltl-cased wells:OR'LINER a licable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESSI MATERIAL
O ft C,/fL I in.
Company Name
J y� 16.INNER'CASING OR:TUBING' e`otherinal'dosW46o'
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2.Well Construction Permit#: 1 - t -��J)o jig - 601�� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft In.
3.Well Use(check well use): ft• tL in.
17.
Water Supply Well: FROMCRE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public ft. fG io'
Geothermal(Heating/Cooling Supply) e idential Water Supply(single) fL ft In
Industrial/Commercial E3Residential Water Supply(shared) 78 GROUT
Irri atiou FROM I TO MATERIAL EMP NT METHOD&AMOUNT
Non-Water Supply Well: ft. 0 ft.
Monitoring Recovery ft. ft
Injection Well:
ft. ft
Aquifer Recharge Groundwater Remediation
19:cSAND/GRAVEL.YACK if:a. licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®IStormwater Drainage ft ft
Experimental Technology ®ISubsidence Control ft. ft
Geothermal(Closed Loop) [ITracer 20,DRILLING LOG attach additional sheets iff:uecessa
Geothermal eatin C oling Return) i Other(explain.under#21 Remarks FROM TO iG DESCRIPT ON color hardo wit/rack rain size,eta
ft
4.Date Well(s)Completed-5 Well ID#_ _ ft. ft s girl, d4&Q I'c
5a.Well Location: 0 ft. G e l }c
O 0 5 p 6! fL ft.
Facility/Owner Name Facility ID#(if applicable) ft• fL
�l ft. ft
75 G4 OoP9' ) C4 in'S,S�
a
'Cal Address,City,and Zip ft fL
— I ][o IZ 21.REMARKS
County u Parcel Identification No.(PIN) rrrataon processing Unit
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certitica'on:
N W
6.Is(are)the well(sRermanent or Temporary Signature of Certified WI 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: ®Yea or No with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction informatio 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 thisforrn.
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 t
9.Total well depth below land surface: 14 5- 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2Qa 100) construction to the following:
10.Static water level below top of casing: O (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 form within 30 days of completion of well
12.Well construction method: l/T / tZ) ' 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) 20 Method of test: ( 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
13b.Disinfection type: 4 Amount: O z completion of well construction to the county health department of the county
where constructed. I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource's Revised 2-22-2016