GW1-2021-01016_Well Construction - GW1_20210419

�l s�e� l i >✓ u Wv Pnnt Form
:may;CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES 'p
Well Contractor Name FROM TO DESCRIPTION
•�� r�`'
It. ft
2080-A fL iG
NC Well Contractor Certification Number 5-6 r 1
15.OUTER CASING for multkasetl Wells)-OR LINER ifs-licable
Aqua Drill, Inc. FROM TO ft. DIAMETER THICIINESS M
Company Name vATERrIA/L
/� ft. 6 % � in. D i i t/ '
/C� / � j^-'7 / .16:INNER CASING-OR�TUBING: �eothermafclosed-loo
2.Well Construction Permit#: l 1� _I '—esjoi a)2,—o z96 FROM I TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) it. ft. in.
3.Well Use(check well use): & ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural i_;Municipal/Public 0 ft ft in.
Geothermal(Heating/Cooling Supply) Ok-idential Water Supply(single) —ft R
Industrial/Commercial DRtsidential Water Supply(shared)
18.GROUT -
Irrigation �FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: V fL fa au C_
Monitoring DRecovery ft. It.
Injection Well: ft. ft.
Aquifer RechargeD Groundwater Remediation
19.SANDIGRAVEL PACK rf a licable
Aquifer Storage and Recovery OSalinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. fr.
Geothermal(Closed Loop) DTracer 20.DRII LING.LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIsrrox color,hardness soiUrock a rain sae err
J 1_ ft. ', ft
4.Date Well(s)Completed: O nt Well ID# -ft. 90 ft'
5a.Well Location: h)I Ar
ft. ft.
Facility/Owner t
COwnerName '\ 7 Facility ft. f
Ll6 1 •, blg,?J q �t� IJ IG 1 CI!)j�p N'(5 ft ft.
®p
Physical Address,City,and Z• ^^ , r. �� i
� pC 7`/7 6� ft ft. � � e
! ! [5)?_� 21:REMARKS _County Parcel Identification No.(PIN) A P R 1 y
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t tl: i ,�;� <,
(ifwell field,one lat/long is sufficient) 22.Certification: d V11"g-Cfti1
N W
6.Is(are)the well(sPermanent or DTemporary Signature of Certified WeTrContzact& ate
By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or 204o with 15A NCAC 01C.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 i: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 I 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: I v (ft-) 24a. For All Wells: Submit this form within 30 days of.completion of well
For multiple wells list all depths ifdifferent(example-3@2000''�and 2@,100') construction to the following:
10.Static water level below top of casing: >2 V (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: I'1 f 8 1z 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) Method of test 1 24c.For Water Suyyly&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:--f--'--r— 14 Amount: 67 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016