GW1-2021-06173_Well Construction - GW1_20211025

p' P�.�int Form t;-
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRD'TION
ft. ' ft
2080-A Im
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells:OR LINER'if iC 7icable
Aqua Drill, Inc. FROM To I DIANAMTE 1 THICKNESS I MATERIAL
ft. 11 it in. �/r> ) f
Company Name C- ,
16♦INNER CASING OR TUBING eothermal closed loo ?-
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits Fe.UIC,County,State,Variance,etc) �ft _
fL3.Well Use(check well use): ft. tn.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agricultural unicipal/Public ft. ft, in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft % in.1
Industrial/Commercial Residential Water Supply(shared)
18.GROUT:
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. ^0 fL
t
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge 13Groundwater Remediation
19.SAND/GRAVEL PACK.if:a' livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft, ft.
Experimental Technology E3Subsidencc Control ft. %
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks FROMI TO DESCRIPTION(color,hardness,wilfrock type,Umin size,etc
ft. ft d
: , 0?4.Date Well(s)Completed �/Well ID# It. /Q OL d Z,
5a.Well Location: 60 ft U
ft. fL
Facility/Owner Name Facility ID#(if applicable) ft. It.
3 2�n t ft. ft. 21
Physical Addre , ity,anAZiJ ft. %
•t1
1 V 21:REMARKS CO
County s T 'Y' (PEN)Parcel Identification No.(PEN) D'O wR Ser
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C;M,"
N W ' /
6.Is(are)the well(sPermanent or Temporary Signature of Certified WeIrContractor Date
O 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: 13Yes or 0 with 15A NCAC 02C.0100 or ILA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information an lain the nature of the copy oj[his 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: (� 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@20 'and 2@1001 construction to the following:
10.Static water level below top of casing: ((J D (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
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: IZ 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 Wm)_� Method of test: i 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: 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 i Revised 2-22-2016