GW1-2021-02252_Well Construction - GW1_20210514

Prin Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
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1.Well Contractor Information:
Chris King ..�
e 14.WATER ZONES'
Well Contractor Name
FROM TO DESCRIPTION
2080-A 4 2021 166R. i( fL o &iFM
fL ft.
NC Well Contractor Certification Number pc�g1C1, U"
IIy1^vIn'3t'on rprQc.. � 15.OUTER'CASING formalticased;wells:ORLIIVER rf:a'licabie
Aqua Drill, Inc. L)"NR Ssci;on RO R. `TTO ft DIAMETER in I �t7 MATE
Company Name //��
VI /� I 16 INNER-CASING OR T[JBING eothermal!dosed-loo t
2.Well Construction Permit#: / FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft,
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.'SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ff, ft. in
Geothermal(Heating/Cooling Supply) estdential Water Supply(single) ft. ft. in,
Industrial/Commercial [3Residentiai Water Supply(shared)
18 GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q R' ® R Z J
Monitoring Recovery R. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19 SAND/GRAVELPACK if.ii ilicdble
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage R• ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20'DRILLING.LOG iittach ad'diti6nil ibe6b if xied6sa
Geothermal eating/Cooling Return Other lain under#121 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,gratc dze,ete
ft. ft
4.Date Well(s)Completed: - Well ID# R• �{ ft. d C
5a.Well Location: qg fL
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ft. fL
Physical Address,City,and Zip L.© i ft, ft.
31�REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certilicati n:
N W _� ��t•
6.Is(are)the well(sermanent or 13Temporary Signature o 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: DYes orXINe with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and 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: + O 5� (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 1@100) construction to the following:
10.Static water level below top of casing: �0 (fL) Division of Water Resources,Information Processing Unit,
lfwater 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
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method f 2 t I 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
13a.Yield(gpm) 10 Method of test: 24c.For Water Supply&Infection Wells: In addition to sending the form to
Qthe 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.
Forth GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016
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