GW1-2022-04151_Well Construction - GW1_20220425

P'i- Form
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 / D fr' 49
fr. ft.
NC Well Contractor Certification Number r15 OUTER CASING for multi-cased welts OR LINER if"plincable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 177 O It. It. ��C in.
y� ?16 INNER CASING OR TUBING" eothermal closed-loop):,
2.Well Construction Permit#:;� � t��11�J q� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits i.e. IC,Coun ft. ft. in.
pp p (' ty,'State,Y lance,et�
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TRICKNESS MATERIAL
HF-JAgricultural Municipal/Public 8. ft. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft.
Industrial/Commercial esidential Water Supply(shared) 18:GROUT '
- Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well; ft. 0 It.
Monitoring EIRecovery ft. ft.
Injection W11:
ft. ft
A e
quifer Recharge DGroundwaterRemediation
=d9.'SAND/GRAVEL-PACK if a licable"' '
+Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IOStorinwater Drainage ft. ft.
:-)Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG'attach additional sheets if necessary)',
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) fr ft.
FROM TO DESCRIPTION color,hardness,soilfrock e, fain size,etc)
4.Date Well(s)Completed: .�eH ID# ft. CC rt'ft.
Sa.Well Location: � ft. �J �It, Z la `�
I'MertCOS y 'y'e' ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft
r ft. fL
0 _t"1't A h Sty � 1�1n, j/ j, _
Address Physical ,City,and Zip ft ft.
of /'Y,G�1 IJ1 21.REMARKS a k s
County Parcel Identification No.(PIN) O
"VL-5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.CertifiC tion:
ri r,•
N W
6.Is(are)the well(S)6ermanent or OTemporary Signature of Certified Well Contractor Ilate
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or []No with 15A NCAC 02C.0100 or ISA 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 retard has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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 form within 30 days of completion of well
For multiple wells list all depths if different(example-33@@200'and 2@1003 construction to the following:
10.Static water level below top of casing: 61,6 (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
11 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: //� l7iL l J L construction to the following:
(Le.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) 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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016