GW1-2021-02248_Well Construction - GW1_20210514

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.;WATERZONES
FROM TO DESCRIPTION
Well Contractor Name
c�aY 1 2021 ft. it.
2080-A
Ul�it ft. ?0
NC Well Contractor Certification Number �E CEcSIC1t) t
t +' co .I5.'OUTER CASING far multi-cased wells OR-LINER if a licsble
Aqua Drill, Inc. � a�F�3®�JR JsC1t0n FROM TO DIAMETER THICIINEss MATERIAL
® rt. (� fc in. r/g
Company Name 7
>'16 INNER CASING OR=T[)BING eothermal'elosed-loo -.
2.Well Construction Permit#: I.0 ri FROM I TO I DIAMETER I THICKNESS LAVIATERML
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): It. I %
Water Supply Well: FROMREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public ft. it. in.
Geothermal(Heating/Cooling Supply)(, Residential Water Supply(single) fL ft.
Industrial/Commercial Residential Water Supply(shared) 18'GROUT .
IrTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft' 0 ft
Monitoring Recovery ft. %
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19 SAND/GRAVEL=PACK ifii"licable .
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
LJ
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft. %
Geothermal(Closed Loop) Tracer 20S DRILLING LOG.5ttachsdditioiialaheet3 if necessa
Geothermal eatin COohn Return Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardn aoiUrock grain s' etc.
ft. ft. C t
4.Date Well(s)Completed:V-23`2/Well ID# [t. it d
5a.Well Location: j L� ft (:� t
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Physicaa/t Address,City,and Zip Ifs. %
21;REMARKS ''
County Parcel Identification No.(PIN) 13 _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latflong is sufficient) 22.Ce ti
6.Is(are)the weil(s)RIPermanent or 13Temporary rgnature of Certified Well Contractor Date
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: E3Yes or/§NO with ISA NCAC 02C.0100 or ISA 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-i is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1 (� — SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ! —d L, 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 t(@200'and 2@1001 construction to the following:
10.Static water level below top of casing: '30 (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: fO (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
I t above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: `' I construction to the following:
(Le.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)� � Method of test: 6 t 24c.For Water Supply&Iniection Wells: In addition to sending the forms to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: = 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
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