GW1-2022-04624_Well Construction - GW1_20220510

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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
k. fL
NC Well Contractor Certification Number 15.OUTER CASING for multi casediwells OR LINER if a livable
Aqua Drill, Inc. FROM TO DIAII�TER THICKN�EjSS MATERIAL
ft. �g in. .D O
Company Name O
f 16INNER CASING OR TUBING(geothermal closed-loo '
2.Well Construction Permit#:L/! ? - .*U.Z FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pe it�UIC,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): k. ft. rn•
Water Supply Well: FROM
ROM TO DIAMETER i SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public k. ft. in.'
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
r hri ation FROM TO^^ MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: k' V ft.
Monitoring _ Recovery ft. ft.
Injection Well: k, ft.
_ Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
_l Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. it
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets it necessary).
Geothermal(HeatinglCooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,willrock in size,etc.
I ft.
4.Date Well(s)Completed:`7- S-� ZWell ID# ft. ft.
Sa.Well Location: k. ft.
LIDA-r-� ft. ft. R P r. ,
Facility/Owner Name Facility ID#(if applicable)
ft. tL '^
y'92 6 n►`z 2 ,/��'yd 1�/ ft. ft MAY i O 2022
Phy'cal Address,City,and Zip fL ft
/ f�le p 21.REMARKS A BOG
County L 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(s) P rmanent or ®ITemporary S ature of Certified Well Coffmctor V Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or 00 with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe 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: 2 (� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J 45 v (N 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-33@-200'and 2@100D 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: Y (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
/ above,also submit one copy of this form within 30 days of completion of well
12.Welt construction method:a//Z- C/'z/I/ 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) �Q © Method of test• s/ 24c.For Water Supply&Injection 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
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