GW1-2021-04304_Well Construction - GW1_20210430

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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 FROM TO DESCRIPTIO
2080-A ft. rL I t
ft. f4
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Aqua Drill, Inc. FROM TO DIAMETER��,, THICKNESS MATERIAL
". d ft / I -`f t /
Company Name _
16.INNER CASING OR TUBING(geothermal closed-loop)
2.We]I Construction Permit#:4_^ / ^C b 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 E3Mtmicipal/Public ft. ft. in.
:]Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
Industrial/Commercial esidential Water Supply(shared) 18.GROUT
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ; t) ft.
Monitoring DRecovery ft. ft.
Injection Well: ft. R.
I Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage fL ft.
J Experimental Technology Subsidence Control ft. ft.
_J Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach,additional sheets necessaryy
_ Geothermal (Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soitl o k e, rain size,etc.
ft. fL C �zd
t
4.Date Well(s)Completed: Well ID# ft. ft. gbck
(�5a.Well Location: i^ C ft. 22r"
t
Facility/Owner Name Facility ID#(if applicable) ft. ft.
aYy/7�GdiJ I: vC `C' �`
Physical Address,City,and Zip ^ /� T ft. ft.
'f �� •G l 1 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: a '
(if well field,one lat/long is sufficient) 22.Certification:
N W
6.Is(are)the well(s) Permanent or Temporary Signatur of ertifi d W Con ctor Date
10 By signing this form,I hereby certijy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or EgNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this 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
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9.Total well depth below land surface: J (ft-) 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 2@100D construction to the following:
10.Static water level below top of casing: (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: (.S� (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
,/tom above,also submit one copy of this'.form within 30 days of completion of well
12.Well construction method: 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) V Method of test: J t 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 0 Z. completion of well construction to the county health department of the county
where constructed.
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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