GW1-2022-04623_Well Construction - GW1_20220510

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King WATER ZONES
Well Contractor Name FROM TO
DESCRtP,TION I'
ft.
2080-A
ft, ft
NC Well Contractor Certification Number 515.OUTER CASING"for m�ti cased wells OR LINER ifa ticable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIA/L,.
Company Name
O ft. 1- 2 ft in. ;a d d )I/I//
p-�/ ',,/ '_16;INNER:CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: 7�G1/!�/'� �� FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,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 DMunicipal/Public ft, ft in.,
Geothermal(Heating/Cooling Supply) eFygesidential Water Supply(single) ft. ft in.
lndustrial/Commercial OResidential Water Supply(shared) 18 GROUT
_i Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 2d ft.
Monitoring 13Recovery ft. ft
Injection Well: ft. ft
3 Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSaBity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft
Experimental Technology E)Subsidence Control ft. ft
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/rack type min size,etc.)
ft. 6 ftRc i+` [
4.Date Well(s)Completed: � �Well ID# is f e
5a.Well Location: ft. ft
ft. fL
P,
Facility/Owner Name Facility ID#(if applicable) ft. ft ti
ft. ft MAY
Physical
�Address,City,and Zip ft. ft.
e 1 ink
21.REMARKS o e.
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:
6.Is(are)the well(sPermanent or Temporary gn St� aN�re of Certif�d Well Cone w 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: E3Yes or/6N0 with 1 SA 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 ofthe copy ofthis 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-I 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: 3 i?,5— W-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@220000''and 2@1001 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 Iniection Wells: In addition to sending the form to the address in 24a
�/2 /�, above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: G 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) . e� D Method of test: 24c.For Water Supply&Iniection Wells: In addition to sending the form to
�3 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount• completion of well construction toi 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