GW1-2021-00133_Well Construction - GW1_20211213

�I?rint Form .
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14 WATER ZONES
Well Contractor Name FROM TO ft• DESCRIPTION
2080-A ao J
NC Well Contractor Certification Number 410ft. 4 it. /O 'I M
15.OUTER CASING`(for multi cased wells OR'LINER;tfa licabk
Aqua Drill, Inc. FROM TO DIAME R THICKNESS MATERIAL
ft. 0 ft.
/ in. g U
Company Name O
pC_ 16.:INNER CASING OR TUBING m eotberal closed-loop);
2.Well Construction Permit#:CIQ OO 4''--Gr/'V 1.l FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) k. ft. In.
3.Well Use(check well use): k. fL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THI11 CKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) k, ft in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft- O ft. J
Monitoring pRecovery ft. ft.
Injection Well: k ft.Aquifer Recharge Groundwater Remediation _
19 SAND/GRAVEL PACK it a''licable
Aquifer Storage and Recovery �Saliniry Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology ®)Subsidence Control k. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heatin Coohn Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,gnin size,eta)
�y ® k. ft
/4.Date Well(s)Completed;/ -23- Well ID# "�' 2 k' tt' 5A/ 6 IZpC� 3;
/13 5a.Well Location: t' 8 ft 1�!UC
ft. ft. -.
q Facilityy/Owner Name Facility lD#(if applicable) ft. ft.
p20o_3 ( -tPin crlLL nou l (Y[Z('�/ArYh DV, ft. fL
Physical Address,City,and Zip �7 � ft. It. fj©
21.'REMARKS z
1 =f�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laUlong is sufficient) 22.CertitiCa'on:
N W
6.IS(are)the well(s)I ermanent or Temporary S ture of Certified Well Con ctor ate
/_ By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E3Yes orAKNo with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy ofthis record has been provided to the well owner.,
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 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 ifdifferent(example-3@20aa*and 2@100') construction to the following:V 10.Static water level below top of casing:�3 (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
/l �� ` f above,also submit one copy of this form within 30 days of completion of well
/Z 12.Well construction method: /�/1 7_ 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
a
13a.Yield(gpm) Method of test: 29c.For Water Supply&Iniection Wells: In addition to sending the form to
:30the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 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