GW1-2021-02246_Well Construction - GW1_20210514

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King t��'e l��°�f�� 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A 4 2021 619 ft. U I
t�1A`( 1 �. ft
NC Well Contractor Certification Number Unit- 15.OUTER CASING for mulfi cased'wells OR LINER if a licable
rocessin9
Aqua Drill, Inc. InlorrraWl, c,�Ct;Un FROM TO DIAMETER 77nCKNESS MA
O ft. in. I 1/0 17 rl1
Company Name 5 q ) ✓) 16.INNER CASING ORTUBING eothermal closed-loo `v
2.Well Construction Permit#: �C 6✓"N o`er I 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. ft in.
17.SCREEN
Water Supply Well: -
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
'Agricultural OMunicipaVPublic g, It. in.
Geothermal(Heating/Cooling Supply) .residential Water Supply(single) ft ft in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft Cern '71oJ /
Monitoring pRecovery ft. ft
Injection Well:
ft. ft.
Aquifer Recharge 13Groundwater Remediat]Rcmarks)
19.SANDIGRAVEL'PACK'if Applicable)
Aquifer Storage and Recovery Salinity BarrierFROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �,Stormwater Drainage
ft. ft
Experimental Technology Subsidence Controlft R.
Geothermal(Closed Loop) E3Traeer 20.DRILLING LOG attach additional sheets if necessary)
r Geothermal(Heating/CoolingReturn) _�Other(explain under#2FROM TO DESCRIPTION color,hardness,soil/rock a grain size,etc
ft. ft I
4.Date Well(s)Completed: — Well ID# ft. ft 5 1
5a.Well Location: S vL -
ft. ft
Facility/Owner Name Facility ID#(if applicablle){. ft. ft.
/ L " 1 ki' ft. ft
Physical Ad ress,City,and Zip ft. ft
Al n miq/r'Cif
31.REMARKS
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.Certific n•
N W
6.Is(are)the well(s) manent or Temporary Sil5iature of Certified Well tontractol Date
r By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes Oro with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information an explain the nature ofthe 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 ifdifferent(example- @200''and 2@I00) construction to the following:
10.Static water level below top of casing: L`D (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: /Y (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
7 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1/Z �� 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
139.Yield(gpm) Method of test: 1A 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: ITA Amount: 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
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