GW1-2022-04166_Well Construction - GW1_20220425

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 6 61
ft. ft
NC Well Contractor Certification Number "15.:OUTER CASING for multi-cased wells OR LINER if a licable
Aqua Drill, Inc. FROM To DIAMETER THICKNESS MATERIAL j
Company Name
2 �"I � � �16:INNER CASING OR TUBING(geothermal closed-loop) -
2.Well Construction Permit#: (J FROM TO DIAMETER THICKNESS rt RIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft �, in. pt✓.!�
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [IMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) ,Residential Water Supply(single) ft. ft in.
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
— Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: " ft. ft.
Monitoring 011ccovery ft. ft.
Injection Well:
ft. ft
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable
Aquifer Storage and Recovery IDSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
HGcotherrruil
FROM TO DESCRIPTION(color,hardness,soit/ruck e, rain size,etc.)
eating/Cooling Return) Other(explain under#21 Remarks) 0 ft. � ft zeG/ (,/
4.Date Well(s)Completed: _ a z Well ID# (j fL It 5fily c: ro Cr—
Sa.Well Location: ft a 9,1c,
ft. ft . i....,? I y 4• 6�
Facility/Owner Name Facility ID#(if applicable) ft. ft
Z2,I5 ,'-41 101A1,e 0 iCt✓.2,9G/,,��c, 2-74- IJr ft. ft s _
Physical Address,Cii�ty,and Zip ft. ft
/ax// "21.REMARKS
County Parcel Identification No.(PIN) 01/<00 1105A&A T J �� 62.1'N-7-&4P Z t -//`�ie
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: f� a-IL-S,/361,Ue /,�L �d /t dGL� 7'/�r✓
(if well field,one lat/long is sufficient) 22.Certificatio : d/mot/� Zd /,0
N W
6.Is(are)the well ermanent or OTemporary Signature of Cer[ifi d 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: OYes or f—JNo 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: / 2- ft-) 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@100D construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,usep 1. 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: T (in-) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
/Z 1 above,also submit one copy of this form within 30 days of completion of well
12.Well.construction method: / y 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: C 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) V Method of test: �J t L' fi 24c.For Water Suably&Iniection Wells: In addition to sending the form to
1 C the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: / Amount: S o 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