GW1-2021-03676_Well Construction - GW1_20210823

VV Lc;ulYSTRUCTIOIiTBECORD GW 1 '' ^
For IDtemal Use 03ily
i.Well Contractor Information:
Chris King
Well Contractor Name 14.-WATER>ZONES.
2080-A
FROM TO DESCRIPTION
t h.
NC Well Contractor Certification Number f. ft y
Aqua Drill, Inc. 15.OUTER CASING formDdt Rwells ORLIIVER 6 liceble
FROnf TO Icl4�IEss MATt�tIAI
C Tt3
ompany Name ft p + /• /y q /
t� �a �( t� in. P11 is Pf 14 2.Well Construction Permit#:= f 'r`'�^ a 7 16 INNER CASING OR TUBING eotherinal closed-ioo
List all applicable well construction p,,nil,l!.e.U/C,Catatrt State Qr�tc t e i/` FROM fL TO DL1Rn3TER
THICIG�IESS nLiTER1AL
ft In.
3•Well Use(check well use):
fL ft• [o.
Water Supply WeII: 17.SCREEN
[Geothermal
cultural ElMunicipaVPublic BROnf TO DIAMETER SLOTCt7R THICt4YESS
hermal ft, i1 in. n1ATERIAi
(Heating/Cooling Supply] residential Water Supply(single)
strial/Commercial QlResidential Water Supply shared ft ft
tion pp y ) X GROUT
ater Supply Wen: FROM TO MATERIAL EMPLACFd3EttT R7ETROD d AMOUNT
toring l-� R tr.
n Well: DRecovery n &
fer Recharge oGroundwaterRemediation ft ft
er Storage and Recovery oSaliniry Barrier -19•SAND/GRAVEL PACK if a licable
er Test FRUM TO MATERIAL
StorMWaterDrainage ft. ft En1PLACEntENTntETBOD
mental Technology EISubsidence Control
ermal(Closed Loop) Tracer f° ft
emtal 20.DRILLING LOG(attach additional sheets if necessnt
(Heating/Cooling Retum) Other(c lain under T21 Remarks) FROM TO DFSCtuPrtoN
t color,herdaes�,soiVryck t e Brain size,ete)
4.Date Well($)Completed:2 f t !G t�
--��Well ID# ft. a_fc �
5a.Well Location: r fc.
t
ft. ft .
Facility/Orvner Name
Facility 3D#(ifapplirable) ft. it:
ft. 1
Physical Address,City,and Ztp r r —'!' tij C J ft. f U$31
t
Counry 31111
23:REMARI{S �r
Parcel Identification No.(PL\)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
017-11 field,one latnong is sufficient)
22.Certification:
6.Is(are)the wells) ermanent or oTemporary Signa�re }ell Contractor ,
Date
7.Is this a repair to an existing well: QYes or No By signing this form,i hereby cent drat the uell(s)star(sere)constructed in accordance
Ij[his is a repair,fit!out knonm well construction information and explain the nature of the CON'ofthis record IrasObeea provrded�o hen•e!/azt0a0`Yel!Cosstnrction Standards and that a
repair trader=21 renrarls 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 ofwells
construction details. You may also attach additional pages if necessary.
drilled:
�i SUBt4IIITTAL INSTRUCTIONS
9.rotal well depth below land surface: "l
For multiple wells list all depths/fdi�erenr(rxomp/e-3(a�1t10'and ZGa Ipp3 (ft') 24a. For All WeIIs; Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: `
/funterlevel is above casing.use-+^ (ft.) Division of Water Resources;Information Processing Unit,
1617 Mall Service Center,Raleigh,NC 27699-1617
11,Borehole diameter: (in.)
qq 24b.For Injection Wells: In addition t`o sending the form to the address in 24a
12.Well construction method: CCU G� i } above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
=WATERUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center;Raleigh,NC 27699-1636
Method of test: 24c.For Water Sumnly&Infection Wells: In addition to sending the form to
type: / the address(es) above, also submit on&copy of this form within 30 days of
Amount cCC � � completion of well construction to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quali
ty ty-Division of W Ater Resources
Revised 2-22-2016