GW1-2021-05545_Well Construction - GW1_20211013

��PrintlForm w
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
F
Well Contractor Name FROM TO DESCRIPTION!0 D f4
2080-A �° ,a x,
k, ft I
NC Well Contractor Certification Number l U���i 15.OUTER CASING for multi cased webs OR LINER if a licable
Aqua Drill, Inc. ��,� ricf'���- FROM TO DIAMETER' THIC/QYESS MATERIAL
v. k. k �� In. Sty/Z II el V,C
Company Name J �Y ��J CJ 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:�/"/r/. 11 t"� —<Dl FROM To DIAMETER' THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) k. ft 1°'
3.Well Use(check well use): ft. ft. in.
Water Supply Well: ""FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft ft
Industrial/Commercial Residential Water Supply(shared) 18:GROUT '
Irri ation FROM I TO MATERIAL�J EMPLACE NT ME OD&AMOUNT
Non-Water Supply Well: O ft. /'� tL
Monitoring Recovery ft. ft
Injection Well:
k. ft
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM I To MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft
Experimental Technology DSubsidence Control ft. I ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets If necessary)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks FROM TO DESCRIPTION color,harda wiurock rain a etc
O k ft CI'✓1
4.Date Weil(s)Completed• Well ID# ft tt W
5a.Well Location: ft L
ft ft.
Facility/Owner Name Facility 1D#(if applicable) ft. ft
I 1� ft f.
Ph s�ddress,City,and Zip ft. ft
G 21.REMARKS
ikQ County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laUlong is sufficient) 22.Certification:
N W r _�
6.Is(are)the weil(s Permanent or E37remporary S ature 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: E3Yes or [3No with 15A NCAC 02C.0100 or I5A 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: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-33@200'and 2@1001 construction to the following:
10.Static water level below top of casing: Cn (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
nn ` above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: //L d,� ( lT_ constriction 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
C L 1
13s.Yield(gpm) S Method of test: R 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also subniit one copy of this form within 30 days of
13b.Disinfection type: Amount: L V completion of well construction to the county health department of the county
where wnstructed. {
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016