GW1-2021-06143_Well Construction - GW1_20211025

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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 ni
O DESCRIPTION
2080-A ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER da livable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft t;z It. in. 512IZ,�Z/ 1 /6/ Ce
X f Va ���/f A6.INNER CASING OR TUBING eotbermal elosed-loo
2.Well Construction Permit# U FROM I To I DIAMETER THICKNESS MATERAAI
List all applicable well construction permits r.e.UIG County,State,Variance,etc.) IL It.
in.
3.Well Use(check well use): k' ft. in.
47.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. ft. in.
Geothermal(Heatingicooling Supply) g
esidential Water Supply(single) ft. ft. in•
'lndustrial/Commercial esidential Water Supply(shared) 18.GROUT
Irfi ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: © ft. ft s C
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.Aquifer Recharge Groundwater Remediation
19:SAND/GRAVELYACK'ifa" liceble
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/CoolingReturn Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardacss soiUrock a is s' etc
O e. G rL
4.Date Well(s)Completed: Well ID# t� ft. s rL d )z oG
5a.Well Location: S` ft. S 7 G� -'/ t C
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
�9-26 F/a f a -1°,C 14d, ,�e,��v�tLry- it. FL
Physical Address,City,and Zip '2?2 o 9 ft. ft.
21 REMARKS QEes
County Parcel Identification No.(PIN) DWR SBcbon
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if welt field,one lat/long is sufficient) 22.Certifica'on:
6.Is(are)the well(s)&Permanent or 13Temporary Signature ofCerti ted Well Contractblr 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: CJYes or [3No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
lfthis 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: (B) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 1@1001 construction to the following:
10.Static water level below top of casing: a y (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection 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: A7/'2 Li/Z i / construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
[13a.
WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Disinfection type: Amount:e Z 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