GW1-2021-06104_Well Construction - GW1_20210809

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES,
Well Contractor Name FROM TO DESCRIPTION
2080-A �Ch- ft- I t�►M
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mulli-cased wells OR LINER:if a 6cable
Aqua Drill, Inc. FROM TO DIAMETER
Company Name THICKNESS MA7FRrAr.
Q ft. Cat ft in.
c�
3$��� 16.INNER CASING OR TUBING eothermal closed-loo 3
2.Well Construction Permit#: DD FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UiC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): h• M in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agricultural E3Mtmicipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft in;
IndustriallCommercial Residential Water Supply(shared)
s 1&'GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: v ft. 2 "'
Monitoring DRecovery @. ft.
Injection Well:
Aquifer Recharge 13Groundwater Remediation ft ft.
19.SAND/GRAVEL PACK(if;a' llcable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage % ft.
Experimental Technology Subsidence Control ft. fL
Geothermal(Closed Loop) Tracer 20 bRILLINGLUG attach additioaelsheetsaf necessa
Geothermal (Heating/Cooling Return) r30ther(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,soi0rock type,grain size,etc
ft- ft
4.Date Well(s)Completed: Well ID# G ". /5-- tt
5a.Well Location: J 5 R' 7Qs ft
ft. ft.
Facility/Owner Name Facility ID#(if applicable) R• ft. `
ft ft Qi�m
� L790 i3c)3 fNy,� T,4;i 6ord,'tika �.
Physical Address,City,and Zip It. f Q Q
21.REMARKS ' +
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
lion proces A10-it
an
(if well field,one lat/long is sufficient) 22.Certification:
N W
6.Is(are)the well(s)A*ermanent or Temporary Sigi9mri of Certified Well Contractor Date
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 oroo with 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 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: 249 S_ (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@@2200'and 1@I001 construction to the following:
10.Static water level below top of casing: J (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: b (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: fq 1z' I 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 SUDDIV&Injection 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: 3d ®�'— 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