GW1-2021-00994_Well Construction - GW1_20210419

Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
FROM TO, DESCRIPTION
2080-A
Well Contractor Name V/ ft �85 ft L r S
ft. ft
NC Well Contractor Certification Number 15.,OUTER CASING for multi cased'wel►s OR LINER if a livable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. / in. 5 0- ^ r , V 4
Company Name u .e
I 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: 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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_
Agricultural [3Municipal/Public ft• ft in.
Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft. ft. in.l
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: © ft. ft. oniCe
Monitoring ORecovery ft. ft.
Injection Well: ft. ft.
J Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®IStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soilfmck e, rain size,etc.)
Geothermal(Heating/Coolin2Return) Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: J 1 L Wed ID# ft. 5- fL 5ow lr�nc
5a.Well Location: ft. S ft UC 41 +C
ft. ft ao O N 19.
�m
Facility/Owner Name Facility ID#(if applicable) ft. ft
3� q 5 k 1 J d- IL---' ft. ft
Physical Address,City,and Zip r2 7�� O ft• ft
21.REMARKS ,1►' ;
County Parcel Identification No.(PUN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification:
N W6� -
6.Is(are)the well(s) Permanent or Temporary Si tune of Certified Well Contractor Date
p�� By signing this form,I hereby certify that the well(v)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or Al R with 15.4 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 Cand'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-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: 3 D ,S- (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 2@100) construction to the following:
10.Static water level below top of casing: V ® (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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: /7 1 12 C=2 1 >' 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) S Method of test: t �1 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: 4 Amount: 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