GW1-2022-01669_Well Construction - GW1_20220128

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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
2080-A Sa ft. s- tL
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LIlVER il a licable
Aqua Drill, Inc. FROM TO DIAIt�TER THICKNESS MATFR/rar.
ft. '3 5-ft_ ��s in. /�2 Z/ 1 L d
Company Name �
I ® , 16.INNER CASING OR TUBING eotherm 'al tiosed-loo
2.Well Construction Permit#: (f l �•16 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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) E3Residential Water Supply(single) fL ft. in.
Industrial/Commercial E3Rcsidential Water Supply(shared) 11 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. b ft.
Monitoring Recovery ft. ft
Injection Well: rVt ��
ft. ft.
Aquifer Recharge Groundwater Remediation
19:;SAND/GRAVEL PAC K`if a"'liCliler - ; � ,
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test CIStormwater Drainage ft. ft.
Experimental Technology ®I Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20:'DRILLING:LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) E30ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc
ft. tt.
4.Date Well(s)Completed: Well ID# 3 ft• S® IL 5 rq h f
5a.Well Location:(^ t 30 ft. t' G /Z/4 I
(Y)ar-� sr 1�� ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft
6-22 o J3ea m sAc u tZ I�c21nJr_ S"/.�11 P ft. ft
Physical Address,City,and Zip rV t C 7),O e� _ ft fL
21.REMARKS
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.Certifiea' n:
N W
6.Is(are)the well(s)OPermanent or Temporary Signature ofCertifie We0 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: [3Yes or io with I5A 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: 95 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I (fL) 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@I00) construction to the following:
10.Static water level below top of casing: Srt� (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use
"++" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: t0 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
n above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: /�l(I-- ciz> construction to the following:
(i.e.auger,rotary,cable,direct push,et.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: G 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) S Method of test: J 1 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: T f Amount: IO d Z 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 i Revised 2-22-2016
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