GW1-2012-05436_Well Construction - GW1_20120514

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Chris King I 'J "' 14:WATER ZONES
Well Contractor Name FROM TO DESCRIPTI N
2080-A Pr1AY 1 4 2021 aft 35
ft. ft
NC Well Contractor Certification Number IrtaGilM���'D�CQGDS9An9 Ulll� 5.OfUTER CASING form DL;MEerd wells):ORLINER ss a HMble) AL
Aqua Drill, Inc. ovy-R se-Y%0n
In. 13 i
Company Name ` O V
INNER CASING:OR TUBING' eotbermal dosed400
2.Well Construction Permit#:e;z - - S FROM TO DIAMETER THICKNESS MATERIAL
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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) ffResidential Water Supply(single) ft ft in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft t `
Monitoring 13Recovery ft. ft
Injection Well: ft. ft
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK:if ii li6ble
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METROD
Aquifer Test E3Stormwater Drainage ft ft
Experimental Technology 13 Subsidence Control ft tt
Geothermal(Closed Loop) ®ITracer 20.DRELLINGLOG Attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardnesN soturock type,grain siza,etc
(� ft. ft d ( ra
4.Date Well(s)Completed: I \ Well ID# ft 7,0
ft rj a /C
5a.Well Location: 2,0 ft 29 0ft61cic
d ft <"t d
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Physical Address,City,and Zip ft. ft
31:REMARKS '
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.Certificati
n / 1
N W
6.Is(are)the well(s) ermanent or Temporary Signature of Certified Well Contractor Date
ON
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: [3Yes. or N0 with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
`"" co o this record has been provided to the well owner.
Ijthis is a repair,fill out known well construction information and explain the nature of the PY .f
repair under#21 remarks section or on the back ofthis 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 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 if dijjerent(example-Sr@@2200'and 2@100) construction to the following:
10.Static water level below top of casing: C�0 (ft.) Division of Water Resources,Information Processing Unit,
1f water 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
1 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: f /Z �i construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
i
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: J 24.For Water Supply&Infection 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: 1 V!� 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