GW1-2022-04737_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 ft. 65
ft, ft.
NC Well Contractor Certification Number I5.OUTER CASING for multi-cased wells OR LIIVER if a licable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATRRrwr
Company Name 0 ft. f; ft /�� in. S�/L
3 -�n�hliZ -O l S63 16.INNER CASING OR TUBING(geothermal elosed400`
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. IL In.
3.Well Use(check well use): ft' ft in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply)4wesidential Water Supply(single) ft ft In.
Industrial/Commercial Residential Water Supply(shared)
18 GROUT '
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
lGeothermal
on-Water Supply Well: 0 ". O It. vu } tzoCA'
�Monitoring Recovery ft. ft
jection Well:
ft. ft
Aquifer Recharge Groundwater Remediation
19.SANDIGRAVEL PACK4`if a 'livable
Aquifer Storage and Recovery ®ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soillrock e, rain size,etc)
(Heating/Cooling Return) 00ther(explain under#21 Remarks) ft. ft Z�o '
4.Date Well(s)Completed: �'Z ��2-Well ID# s it. 5'Y' it. j KQC dc
5a.Well Location: S IL /Q 5- ft U C /Z ru I
ft ft
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
121 �.e)D�I S�q P i M �tlw�nn P1Z�'1G�G� N 1t ft. ft ,
Physical Address,City,and Zip V✓5—1� ft. ft
M
01� Lk- 21:REARKS
County Parcel Identification No.(PIN) *' ft
'ru�br � g lIfY)I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Y
(if well field,one lattlong is sufficient) 22.Certifl do
N W / 'lam
6.Is(are)the well(sermanent or Temporary Signature of Certified 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: MYes or 6o 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: )V s- (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''a\nd 2@100) construction to the following:
10.Static water level below top of casing: v (fL) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Inlection 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.Well construction method: l ( /Z i-L X ` ` construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: r 1 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: -5k Q )1 ` 24c.For Water Supply&Inlection Wells: In addition to sending the form to
the address(es) above, also submitf one copy of this form within 30 days of
13b.Disinfection type: ZIE# Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016