GW1-2022-04620_Well Construction - GW1_20220510

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
Oft. / ft.
t C-0 at
2080-A ft. ft. V
NC Well Contractor Certification Number 75.OUTER CASING for multi-cased wells OR LINER;if a" Gcable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
b ft, / ft /rg in_
d g 9 Al/
Company Name ! -
�j "]6.INNER CASING OR TUBING(geothermal closed-loo
/
2.Well Construction Permit#:�6 O�z y yy FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Cmmty,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
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 []Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL
-� EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. r� TN j � ?
Monitoring Recovery ft.
d ft.
Injection Well:
ft, ft.
Aquifer Recharge Groundwater Remediation
19.SANDlGRAVEL PACK if a licatile
1 Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test EIStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
J Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary);.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soil/rockatyp rain size etc
4.Date Well(s)Completed: -' Well ID# ft. ft. Aloc
5a.Well Location: ft. ft
ft. ft.
Facility/Owner Name Facility 1D#(if applicable) ft. ft.
C/1,1 ft. ft. `
Physical Address,City,and Zip ft. ft. 5
/4l'o? ►PnJ t a zI:REMARKS
County Parcel Identification No.(PIN)
Unit
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} ermanent or Temporary Signature of Certified Well ContnIctor 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: ®Yes or�No 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: ' (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'aand 2@100) construction to the following:
10.Static water level below top of casing: -5-6 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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� ./2 i � 1 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: /l* G 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
j
13a.Yield(gpm) <- Method of test: 5', h ,I 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: ©'Z� completion of well construction tol 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
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