GW1-2021-00581_Well Construction - GW1_20211222

�• -;-Pr:ii Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES'
Well Contractor Name FROM TO DESCRIPTION
tL
2080-A
NC Well Contractor Certification Number Sot; f L
15.OUTER CASING for s multi cased we OR LINER if a livable
Aqua Drill, Inc. FROM TO DIAMETER TffiCKNESS MATERIAL
Company Name
O ft. D ftI 01g!i
In. 2-z j I t v G
r �1 ^ INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#:L�P1 M� o / FROM TO DIAIv1ETER 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 DMunicipal(Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft.
I Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 9 ft.
Monitoring _ ___._.. Recovery - ft. ft.
Injection Well:
ft. ft
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK ifapplicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage k' I n
Experimental Technology Subsidence Control It. I ft.
Geothermal(Closed Loop) EITracer 20.DRILLING LOG attach additional sbeets if necessary)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks FROM ft. TO DESCRIPTION color,hardness,soil/rock type,grain sizz,etc
4.Date Well(s)Completed::: Well ID# ft. Q�j�fft yv�l d� I L
5a.Well Location: t7�f4 ic�7 C i2 1G
ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft
t��f r�Cn l S-� ,��en1 , C ft. ft
Physical Address,City,and Zip �?4 f/�/ ft It.
0�0 0 21.REMARKS 1
County -r Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certiticati
N W
6.Is(are)the well( ermanent or 13Temporary ftgTt-ure ofCertified Well Contractor I 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: ®Yes o&No with 15A 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 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: . l� (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''aan�d 2@100) construction to the following:
10.Static water level below top of casing: 1
200 V (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
I above,also submit one copy of this�form within 30 days of completion of well
12.Well construction method: / 2 a 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
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13a.Yield(gpm) Method of test: k, - 24c.For Water SuDDIv&Iniection Weals: 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:�o�®Z completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016