GW1-2021-02257_Well Construction - GW1_20210514

Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King _ e� E- 14.WATER ZONES
e FROM TO PTI
Well Contractor Nam DESCRION
2080-A ��p"A,n ft. � ft G. t I�
NC Well Contractor Certification Number ldl l�� 14
� ft• �1 f L � �f�
vYll� 15.OUTER CASING'for mufti-cased wells OR LINER if applicable)
Aqua Drill, Inc. �, ?rat%CcS.CIh FROM TO DIAMETER THICKNESS I MATERIAL
Company Name t QO116.
/� ) 116.INNER CASING OR'TUBING(geothermal dosed-loop)
2.Well Construction Permit#: l FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(ire .U1C,County,State,Variance,etc.) ft. ft In.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) toh,40ential Water Supply(single) ft. in,
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft- AQ ft
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
;.19.SAND/GRAVEL PACK if.a'liable
Aquifer Storage and Recovery [ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) [ITracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return Other lain under#21 Remarks FROM I TO DESCRIPTION color,hardnen,wi0rock type in size,etc.
Ah k. ft. J
4.Date Well(s)Completed: �� / Well ID# R' o tf° N.c C 1
qWell Location: 7 C� fZ ity/Owner Name Facility ID#(if applicable) ft. ft.
'J�S ft. ft.
Physical Address,City,and Zip ft. ft.
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certifieati0 :
N W + J —_J L
6.Is(are)the well(SOPermanent or Temporary Signature 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: [3Yes or Sq�io 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 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-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: _ J (ft-) 24a. For All Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depths ifili ferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: t c (ft.) 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:_ �(Z di-C� 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
�
13a.Yield(gpm) 'C y Method of test: S L q -� 24c.For Water Supply&Infection'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: L,16 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