GW1-2022-01885_Well Construction - GW1_20220210

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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 130 6,
`7t
fr. tt
NC Well Contractor Certification Number 15.OUTER CASING.for multi-cased wells'OR LINER6' a 'hcable a;
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS I MATERIAL
Q ft' 1 it. Y in. 5 t JtC
Company Name
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16:1NNER CASING OR TUBING eothertnalelosed-loo
2.Well Construction Permit#,2/_v5 -6_)n11I2 —10 3Q 22 FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. It.
in.
3.Well Use(check well use): ft. It. in.
Water Supply Well: ,:17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public ft. ft in.,
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in,
'Industrial/Commercial E3Residential Water Supply(shared) 18 GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT.
Non-Water Supply Well: ft. o It. Ce
Cr!C
Monitoring E3Recovery ft. ft.
Injection Well:
ft. ft.
LJ
Aquifer Recharge 13Groundwater Remediation
19 SAND/GRAVEL`-PACK its licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD'
Aquifer Test OStormwater Drainage fr. ft
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) ®ITracer 20.DRMLING LOG attach additional sheets if aecessa
Geothermal(Heating/Cooling Return) 00thcr(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soilhmck type rain size,etc.)
9 Q It.
it
4.Date Well(s)Completed: 3/ ,� wen um 1012� � ft. ,—ft ! � f �C
5a.Well Location: 2 ft' /_6J i t
ft. ft.
Facility/OwnerName � Facility ID#(if applicable) ft. ft
—I G/U Y/ /1(� h►� /� �7 5� (t17L'CYU�1 ��1 IfJ fr. ft. `a `_`� r,
Physical Address,City,and JZip ft. ft O
IZC 31,REMARKS e
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.Certifics' n:
N W
6.Is(are)the well(s)OPermanent or Temporary Signature of Certified el4Con 'r 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 oEJ!3&o with 15A NCAC 01C.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 ojthis 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 surface; (ft) 24a. For All Wells: Submit this'j form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: JO (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 e"
11.Borehole diameter: t0 (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: 4('/'L 1 )Z J 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) 34 Method of test: S['G�t 24c.For Water Supply&Infection Wells: In addition to sending the form to
1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: % Amount: 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