GW1-2022-03828_Well Construction - GW1_20220331

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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
lllo' ie;i
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for multi cased;weUS OR LINER if:a livable
Aqua Drill, Inc. FROM To DIAII7ETER THICKNESS MATF.RiAr.
it g3 ft- in. ,619 1/-1
Company Name
16.INNER CASING OR TUBING eother al closed-loop)
2.Well Construction Permit#: 7 V O�PiG�`` FROM TO DIAMETER THICKNESS MATERUL
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 fr. ft in.
Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft. ft. in.
IndustriaUCommercial Residential Water Supply(shared)
18.GROUT
ni Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. a o ft
Monitoring 011ecovery ft. ft. _
Injection Well:
ft. ft.
J Aquifer Recharge 13Groundwater Remediation
19.1SAND/GRAVEL PACKOf Applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20 DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,wil/mck e, fain size,etc.)
_i Geothermal(Heating/Cooling Cooling Return) (explain under#21 Remarks) Q ft. 6 It KG-.
4.Date Well(s)Completed: -Z 2—We11 ID# ft. -2 9 ft
5a.Well Location: `' S� ft. ys'It lv G Z lZJ�
ft ft
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1 30( Ec nd IW q C-I- -
Physical Address,City,and Zipt ft. tt
&y 11mc,— 21.REMARKS �ry
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:
N W
Z
6.Is(are)the well(sermanent or Temporary 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: [3Yes or [3No 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-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: l (f-) 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@I00) construction to the following:
10.Static water level below top of casing: '30 (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: 404,/z cl121 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
13s.Yield(gpm) / Method of test: St 4 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submitl one copy of this form within 30 days of
13b.Disinfection type: Amount: 2 0Z 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 Revised 2-22-2016