GW1-2021-05551_Well Construction - GW1_20211013

PIn#form
WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 6/ It GI'
2080
NC Well Contractor Certification Number T J 15.OUTER CASING'for multitssed wells:OR LINER; a livable
Aqua Drill, Inc. s�;�c�9V�'�1 FROM TO DIAI1fETER THICKNESS AT MATERIAL
r•P ft. ft- (O f 9., in. s D ( `1v I
Company Name 1 3 O JR J4�10n .16::INNER CASING OR TUBING( eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATFRL4,L
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft• ft in.
3.Well Use(check well use): ft. ft in.
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) "$esidential Water Supply(single) ft ft in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft }
Monitoring 13Recovery ft. ft
Injection Well: ft. ft
Aquifer Recharge 13Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery ®I Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft ft
Experimental Technology ®ISubsidence Control ft It.
Geothermal(Closed Loop) ®ITracer 20.DRILLING LOG.attach additional sheets if necessity)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,wil/rock tyM grain size,etc
6 ft. S ft C
4.Date Wells)Completed -2� Well ID# ft' sD It )zpC C
55a..WellLocation:2 / ft. k 5 7
t ZAN, C
Facility/Owner Name ice— Faaciliitty ID#(if applicable)
`/
Physical Address,City,and Zip ft. ft
�D fL e C 21:REMARxs
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certiticati �f
N W
6.Is(are)the well(s) Permanent or Temporary Si re of Certified Well Confractor 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: 13 Yes or with ISA NCAC 02C.0100 or I5A 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 ofthis 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: (O�� (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(@2200'''and 1@100l construction to the following:
10.Static water level below top of casing: 7S y (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: V (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
�1 ) above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: !/7/2 zl /� construction to the following:
(ie.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: -Siqlt4 24c.For Water Supply&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: Amount' 2 d t7-z— completion of well construction to the county health department of the county
—D where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016