GW1-2021-02254_Well Construction - GW1_20210514

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES i
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
2080-A ft. rt 0'
NC Well Contractor Certification Number ,15.OUTER CASING.for muld4cased`vells'OR-LINNER sip licable
Aqua Drill, Inc. FROM I To DIAMETER THICKNESS IA MATERL
ft. % in.
Company Name a ex"
/0 7�a J4j&�/I 16 INNER CASING OR TUBING eothe'mal el -loS
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATFRIAI.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft ft fin•
3.Well Use(check well use): ft. M in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
IndustriaUCommercial Residential Water Supply(shared) 18.GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. t S
Monitoring DRecovery ft, ft
Injection Well: % it.
Aquifer Recharge Groundwater Remediation
19::SAND/GRAXEI:PACK ifs""liciible '
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft ft
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20;DRILLINGI:OG'atfaeh ad'ditioniii sheetsaf:necessa
Geothermal (Heating/Cooling Return Other lain under#21 Remarks FROM I TO DESCRIPTION solo,hardness,soil/rock e' etc
ft it )p.
4.Date Wells)Completed: Well ID# ft. ft satil 01 QCf.
t 5a.Well Location: 1Uc l
�/V U V�C� BLS V 'rnQ s ft. ft
n /Faci(liity/Ownne�r Name �j � q Facility lD#(if applicable) ft' M
/`0V L (elf!VzUP-1� e—)Ag l,aJO-30 ft. ft
4,P,hnys*al, ddress,City,and Zip ft. ftJA 2L REMARKS
Parcel identification No.(PIN) 202 f
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Information ,�Gsing Unit
(if well field,one lat/long is sufficient) 22.Certifie on: DINR Section
a.� N W w
6.Is(are)the weil(s) rmanent or Temporary Signature of Certified Well Gntractor ate
By signing this farm,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or 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#11 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: U (ft-) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2@100) construction to the following:
C/
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If inter 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
/1 '�� I�jZ lj/ above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Y� l� 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
13s.Yield(gpm) v Method of test: `T 24c.For Water Supply&Injection 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: (O Z completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016