GW1-2021-00528_Well Construction - GW1_20211222

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King IC WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
k. ft
2080-A '
NC Well Contractor Certification Number �O k• I��f L O � t
15.OUTER CASING for multi cased wells OR LINER a Gcable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
,�r� ft, p ft. / in. (L C
Company Name v � � �� (Z
// 16.INNER CASING OR TUBING eothermal closed400
2.Well Construction Permit#: ,D ��k) (�(D 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): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public k. ft in.i
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: k. D k.
Monitoring Recovery ft. ft
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.:SAND/GRAVEL PACK if a'"'licable
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage k. ft
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) Pft.
TO DESCRIPTION color,hardness,soft)o k a rain size,etc
` $ k ainy
4.Date Well(s)Completed: (o-,`t Well ID# ��T ` ' G� ft 1(� ( — L(
C
5a.Well Location: aZ�ftU G Z ft
Facility/Owner Name I' Facility ID#(if applicable) (,.ft. ft i
,2 C/ A I-6 D rJ P14 4 N G INI e'Z� L IC ft. it G •:,,p" )(r;.,
c.�1—r l
Physical Address,City, d Zip 7 35-y k. ft. Q
21.REMARKS I
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 tion:
�,�/ N W
6.Is(are)the well(s) erIDanent or Temporary Signature ofCettified W Contractor Date
(T 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: ®Yes or 13No 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
9.Total well depth below land surfacer (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@l00) construction to the following:
10.Static water level below top of casing: so (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
J'L i � ) above,also submit one copy of this',form within 30 days of completion of well
12.Well construction method: /-1/ C / 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: _ 24c.For Water Supply&Infection Wells: In addition to sending the form to
Q the address(es) above, also submit;one copy of this form within 30 days of
13b.Disinfection type: Amount: —1 C)Z completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016