GW1-2021-02249_Well Construction - GW1_20210514

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King p, 14?WATER ZONES
Well Contractor Name a- FROM TO I DESCRIPTION
2080-A Anv�/ l 21
NC Well Contractor Certification Number �V1 H` 2� 15.OUTER CASING for mul&casedl 1 `
A k. ft. h
q �ra� � U1311 (J V wells) licable '
A ua Drill, Inc. ess:ing FROM TO DIAMETER THICKNESS MATERIAL,
ft.
Company Name []��
16 INNER CASING OR TUBING eotherival-dosed-loo ..
2.Well Construction Permit#:� � l`Y � FROM I TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) % ft. i°' t /S
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLAT SIZE THICKNESS MATERIAL
Agricultural [)Municipal/Public ft. ft, in.'
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. 10,.
Industrial/Commercial Residential Water Supply(Shared)
.1&-GROUT
Inn ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. O it & C(�'
Monitoring E3Recovery ft. ft. d
Injection Well:
ft. ft.
Aquifer Recharge 13Groundwater Remediation
.19:SAND/GRAVEL'.PAGK if ii"lidble '
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20:DRILLING.LOG ettecti additional sheeti:if:neeessa . e-
Geothermal eatin Coolie Return Other(explain under#21 eIkS) FROM TO DESCRIPTION color,hardness,sofUroek grain sLx eta
D ft. ft.
1.
4.Date Well(s)Completed: �L 'Well EW D' ft' hlci �K
Sa Well Location: ft ft5.
W t
ft. ft.
Facility/Owner Name Facility ID#(if applicable) k• D'
I ft. ft y �axzP I.��-"
Physical Address,City,and Zip ft. ft
.4/47 rjLF A 0t o 31;REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/Wnutes/seconds or decimal degrees:
(if well field,one lat(long is sufficient) 22.Certifieati
N W
6.Is(are)the well(s) ermanent or Temporary Sign of Certified Wel Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or)Elmowith 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#21 remarks section or on the back of thisform.
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: ASP 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 1Q100D 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. (in.) 24b.For Iniection 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: 1 C'�L f 1 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
13a.Yield(gpm) V9,O Method of test: l' 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: a 7- completion of well construction to the county health department of the county
where constructed.
Forth GW-1 North Carolina Department of Environmental Quality-Division of Water Resources! Revised 2-22-2016