GW1-2021-00468_Well Construction - GW1_20211222

WELL CONSTRUCTION RECORD(GW-1) For Internal Use only: PrintForm
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A Ct rL 10 6",
t. r(:; ft.
NC Well Contractor Certification Number 15.OUTER CASING'for inulti ased. s OR LINER rf:a livable
Aqua Drill, Inc. FROM To DIAMETER THICKNESS MATERIAL,
ft. ft- a�e in. ,Is y
Company Name �
16.INNER CASING OR TUBING eotbermsl closed-loop)'
2.Well Construction Permit#: 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.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural 13Municipal/Public ft. ft. in. I
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) B, ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[Experimental
ter Supply Well: ft. it
oring Recovery ft. ft.
Jae
_: .
n Well: ft. ft.
r Recharge Groundwater Remediation _
19.SAND/GRAVEL PACK"if ii`6iieable
r Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
r Test 13Stormwater Drainage ft. fL
Technology Subsidence Control ft. ftrmal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessarmal eatin Conlin Return Other(explain under#21 Remarks FROM To DESCRIPTION wlor,hardness soi0roek a is size,etc.
it. ft. d 1
4.Date Weil(s)Completed: _2 Well ID# 5-3Z ft. - ft , GJ aC
5a.Well Location: k. it U Z I
ft. ft
Facility/Owner Name Facility ID#(if applicable) k' ft. 4 h
a.0 57-0 �.�✓N /Z �-/Z 19G► I,yt ru • I,*,- ft. rt D
Physical Address, ity,and Zip ft. fL
�414/YJ /C G_i 21.REMARKS t r.
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.Certification:
N W z- -Z
6.Is(are)the well(s) ermanent or Temporary Signature of Certified Well Contractor 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: E3Yes or o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
0
If this is a repair,fill out known well construction information and explain the nature of the copy ojthis 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: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2(Qa 100") construction to the following:
10.Static water level below top of casing: oS 0 (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 Infection 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: �/// I t 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: 5 rt� t 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: / Amount:(n Z completion of well construction to the county health department of the county
where constructed.
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016