GW1-2022-03842_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
ft S ft. r In
2080-A c.�
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NC Well Contractor Certification Number 15.OUTER CASING for multi-cased swells OR'LINER:Ti "llcable
Aqua Drill, Inc. FROM I TO DIAMETER I THICKNESS I MATERIAL.
ft. g fL16 VG V
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Company Name
, -`W 16.INNER CASING OR TUBING eothermalclosed-loo
_2.Well Construction Permit#: U _CAW
HI? ^02
0 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) h• ft in.
3.Well Use(check well use): ft• ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.`
Industrial/Commercial DResidential Water Supply(shared) 18 GGROUT
M Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
lGecithermal
on-Water Supply Well: ' ft. 9,O fL z u L K
Monitoring Recovery ft. ft.
jection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.+SAND/GRAVEL,PACK if a licableAquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft, ft.
Experimental Technology Dj Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.`DRILLING LOG attach additional sheets;if necessa(Heating/Cooling Coolin Return - Other(explain under#21 Remarks FROM TO DESCRIPTION(color,hardness soiUmck raja size etc.)
^� ® ft. /r ft. �p
4.Date Well(s)Completed: � ell ID# � ft. �S ft. �ti 'Z�C
5a.Well Location: 9 rt' ?S­` My e y C-
ft. fL
Facility/Owner Name Facility ID#(if applicable) ft. ft.
-79 Z ty tS M C h1 CJ U 61 & C&N.S b D IZ O rt. rt )
Physical Address,City,and Zip N 1 C.. ft. ft
21:REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilong is sufficient) 22.Certifi Hon:
N
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4
6.Is(are)the well(SPermanent or OTemporary 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: E]Yes or„ NNo with 15A 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (fL) 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@100) construction to the following:
10.Static water level below top of casing: (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 Injection 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: 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: L L 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)C_ Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit'C one copy of this form within 30 days of
13b.Disinfection type: Amount:Q a-z' completion of well construction to the county health department of the county
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016