GW1-2021-07516_Well Construction - GW1_20210903

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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 DESCRIPTION
D21. fL
2080-A
k. tL
NC Well Contractor Certification Number 15.OUTER CASING for muttl-caeed wells OR LINER if a 'II-bIe
Aqua Drill, Inc. FROM To DIAMETER THICKNESS MA
Company Name
ft. ft In. O V L+1612- `/ L
�� e rw I I 16:INNER CASING OR TUBING eothermai closed ES
2.Well Construction Permit#: (J /l�V FROM TO DIAMETER THICKNESSSS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,'Variance,etc.) ff. ft. In.
3.Well Use(check well use): k. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public k. k. in.
Geothermal(Heating/Cooling Supply)residential Water Supply(single) k, ft. in.
Industrial/Commercial Residential Water Supply(shared) rR GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. O ft
Monitoring DRecovery k. ft.
Injection Well: k ft.
Aquifer Recharge 13Groundwater Remediation
✓19:.SAND/GRAVEL:PACK(if a iicable "'
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stonnwater Drainage (t. ft.
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20:DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return Other lain under#21 Remarks FROM TO DESCRIPTION color,hardness,soft/rock type,grains etc.
Q o k ft-
4.Date Well(s)Completed:V-1 7- Well f im I •k. 5:5- ft. II
Sa.Well Location: 6 S k' C LtT
ft. fL
Facility/Owner Name Facility ID#(if applicable) k. IL
ft. k
Pbcal AddressCity,and Zip ft. ft.�r�� 31 REMARKS
County Parcel Identification No.(PIN)
Informs lon
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: aAon
(if well field,one lat/long is sufficient) 22.Cc ca on:
N W ` a•.
6.Is(are)the weil(s) ermanent or Temporary
Signature of Certified ell Contractor 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: ®Yes or No with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
lfthis is a repair,fill out known well construction informatio nd 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:_T 02— 00 24a. For AB Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdifferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: J Q (ft.) Division of Water Resources,Information Processing Unit,
lfwater 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: A�/ construction to the following:
(Le.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: V ;QL, 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:11= �� 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