GW1-2022-04621_Well Construction - GW1_20220510

Prin#Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King -44.WATER ZONES
FROM TO DESCRIPTION
ft.
Well Contractor Name ,,/11/5- Ci`'
2080-A
ft. ft I
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER ifa licable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS I MATERIAL
Q ft yx ft ,� In-
Company
Company Name
'� INNER CASING OR TUBING eothermal closed-
2.Well Construction Permit#: FROM
s ,J! /'`� FROM TO DI
AMETER THICKNESS MATR.RiAr.
List all applicable well co struction permits(i.e.UIC,County,State,Variance,etc) ft. ft in.
3.Well Use(check well use): ft. ft. in.
SCREEN
Water Supply Well: 17.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural Municipal/Public ft. It. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft in.l
i Industrial/Commercial [3Residential Water Supply(shared) 18.GROUT
Irrl ation FROM TO MATERIAL EMPLACEKENTJNIETROD&AMOUNT
Non-Water Supply Well: ft. tt.00 B`o 1,-04
Monitoring 13Recovery ft. ft.
Injection Well: ft ft
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL'PACK if a'" liciible " T
Aquifer Storage and Recovery [ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology E3Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessa"
FROM TO DESCRIPTION color,hardness,wil/mck rain size,etc.
Geothermal(Heatin Conlin Return) 'Other(explain under#21 Remarks)
(� 6 ft. ft ellO
4.Date Weu(s)Completed:? Well ID# B ft. ft. Q C/C
5a.Well Location: ft. s— ft.
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft
T a
Physical Address,City,and Zip ft. ft I V
21.REMAIR
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
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Mrell Conuhttut 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 I5A NCAC 02C.0100 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy oJthrs record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
e 23.Site diagram or additional well details:
t` You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: u SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: i7 t� (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: 5-0 (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
c above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: �%�/Z I)P—I 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
13a.Yield(gpm) / Method of test: t'Q 24c.For Water Supply&Infection 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 to the county health department of the county
where constructed. t
Form GW-1 North Carolina Department of finvironmental Quality-Division of Water Resource's Revised 2-22-2016