GW1-2021-04684_Well Construction - GW1_20210521

HE
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King Cw`' m 14:WATER ZONES
Well Contractor Name fir'— FROM TO DESCRIPTION
2080-A A^ 212021 - ft. :5 ft. 5- ,
'v1H� v, \}lief �ft• �ft. �v Gl
Aqua DCI NC Well �tor Inc.rtificationNumber ��`{01T3 0� 15. TO
FROM OUTER CASING
RMUTERCASSING formuDtAMETEReyjs TOR_L R a` IlMble L
ft. 63 it. 16 ; In. /g
Company Name 0r
/ - 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#:4/l "�� 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 [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. fa in;
Industrial/Commercial Residential Water Supply(shared)
78.GROUT'
hTi ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. v ft. N t
Monitoring DRecovery ft. ft.
17
Injection Well:
ft. ft.
Aquifer Recharge 13Groundwater Remediation
19.SAND/GRAVELsPACK if s licable
Aquifer Storage and Recovery 13Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. It.
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) ®ITracer 20.DRILLING LOG attach additional sheets.If necessa
Geothermal (Heating/Cooling Retum Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soll/rock type,grain sim etc.
ft. ft t
4.Date Well(s)Completed:12�— Well ID# ft. ft.
ft. ft.
5a.Well Location:
C t
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ft. tL
P 'al Address,City,and Zip ft. ft.
. 21.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.Certifi on:
N W 4�z Z
6.Is(are)the well(06ermanent or Temporary Signature ofCertiiTed Well Confliactor 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: 13Yes or I0 with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repay,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-I 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: e 1 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@100'and 2@I00) constriction to the following:
10.Static water level below top of casing: 30
(ft.) Division of Water Resources,Information Processing Unit,
lf water level is above casing,use ^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: tO (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
.AA above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: �y/Z/l l 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(gpm) Method of test:S I� + 24c.For Water Supply&Iniection Wells: In addition to sending the form to
2 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: I� C 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