GW1-2022-02876_Well Construction - GW1_20220228

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King '14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft.
2080-A
NC Well Contractor Certification Number 15.OUTER CASING(for ulti-casi&weUs)PLkl; R-Cif-apticable
Aqua Drill, Inc. FROM TO DIAMETER SS MATERIAL
Company Name 0 in. 15Dn
A&ANNER-CASINGOR:TUBING'(a6ithermiil d6iid466p)
2.Well Construction Permit#:.2-d 2 16 6 0 0 2Z FROM TO DIAMETER I 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: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:]Agricultural [)Municipal/Public ft. ft. in.
:)5Geothermal(Heating/Cooling Supply) EaResidential Water Supply(single) ffi fL in.
31ndustrial/Commercial [3Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: r. )0. IL
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 13Groundwater Remediation
,19,,SAND/GRAVEL:PXC-K�(if.i:0011ctibli),.
Non-Water
M Injection 0
W n�b a
Aquifer
Aquifer Storage and Recovery [)Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
[Aquifier Test [3Stormwater Drainage ft. ft.
Experimental Technology E3 Subsidence Control
Geothermal(Closed Loop) [3Tracer -20�DRILLING,LOG-(iittach iidditi6hiI sh":if-hecessary):.1._,,
Geothermal(Heating/Cooling Return) E3Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type, in size,etc.)
a . .2 , .0=r-"!
4.Date Well(s)Completed: Well ID# .11 ft. 31� ft. 5h4w L Ec>C/L
5a.Well Location: 39 fL 2.25ft- 1316 &1_1x4M�e-
ft. ft. RFrf;;I\IED
Facility/Owner Name Facility ID#(if applicable) ft. ft.
C170 r6Lre ft. ft. FEB 2 9 UZZ
Physical Address,City,and Zip ft. ft
216 REMARKS woo
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:
6.Is(are)the well(s)OPermanent or [3Temporary 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: r3yes e;E - with 15A NCAC 02C.0100 or 15-4 NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe 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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 4��_�- SUBMITTAL INSTRUCTIONS ,
9.Total well depth below land surface: ft-) 24a. For All Wells: Submit this i'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: 60 (ft.) Division of Water Resources,Information Processing Unit,
I
If water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 (in.) 24b.For Iniection 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: dJz_1* 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) Sv Method of test: 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: Amount: completion of well construction to the county health department of the county
where constructed.
FormGW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016