GW1-2021-03545_Well Construction - GW1_20210607

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
i
1.Well Contractor Information: f
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION _
2080-A ft. rt.
t p
ft. �`ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells ORLINER It a lIcable
Aqua Drill, Inc. FROM TO DIAMETER' THICKNESS MATFRIAI.
Company Name fL 62 �5 fL IP�- in.
16.INNER CASING OR T[JBING eothermal closed-loop) V
2.Well Construction Permit F 011'?52;� 0.2- FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits#.e.UIC,County,State,Variance,etc.) ft. fL in.
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER! SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public k. fY in.1
Geothermal(Heating/Cooling Supply) 4siderltial Water Supply(single) ft. ft. ;n•
Industrial/Commercial Residential Water Supply(shared) 1&GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. (9,0 fL 5erd4q ck° 5
Monitoring Recovery ft. ft.
Injection Well: ft it.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL'PACK if:a' liable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20:'DRILLING.LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardy soil/rock rain size,etc.
ft. ` ft. /a
4.Date Well(s)Completed Well ID fL C•# ft. ,C
5a.Well Location: /� ft L uG •^z IU!4 e
C.�`1S. Ce c� C fY) �u It. ft.
Facility/Owner Name Facility ID#(if applicable) ft• ft.
-1-12)ki5h d R � ryrf 1) ft. fL PC
Physical Address,City,and Zip ft. ft
31.REMARKS I
County , Parcel Identification No.(PIN)
IrioIr:otie;1 {7rcct:ssinq Unit
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1'' t 2CI'On
(if well field,one Iat/long is sufficient) 22.Certificati
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N W
�aCa �
6.Is(are)the well(sPermanent or Temporary 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: ®Yes or 0 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 ofthis 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 All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@@2200'and 2@1001 construction to the following:
10.Static water level below top of casing: (O 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: 24b.For Infection Wells: In addition to sending the form to the address in 24a
/9 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: (r ) construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 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: Amount: Z completion of well construction to the county health department of the county
where constructed.
Form GW-t North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016