GW1-2022-04738_Well Construction - GW1_20220510

P Ir nt Form ,
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
2080-A Q ft. 7 rt. /L� f► '
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-casedwells 0R LINER if a licable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATER�IA(.L
ft. it �/� io. S��/Z P1 V /
Company Name `�
°3�� ���,���`� 6:INNER CASING OR TUBING eothermal dosed-loo
2.Well Construction Permit#: Imo! J FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft 1°'
3.Well Use(check well use): ft. ft. is
17.SCREEN
Water Supply Well:
FROM TO DIAMETER, SLOTSIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft• ft. in.
Geothermal(Heating/Cooling Supply) 4&esideritial Water Supply(single) ft. ft. in
Industrial/Commercial E3Residential Water Supply(shared) 18:GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. /t fL
Monitoring D Recovery ft. vv ft.
Injection Well:
ft. ft. _
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if.a "licatile
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer .20.DRILLING LOG attach.additional sheets if necessary).
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soiUrock a is size,etc.
ft. % ft.
4.Date Well(s)Completed: 2�22—Well ID# r/'� ft. C1 S— ft' s� IZOC
5a.Well Location: `i5 ft. r ft. f��U C Gib r C
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
�6 i\t t_kAtN i 5 S 1 15uppm--lZ Ec�4 N L- ft. ft.
M inn
Physical Address,City,and Zip �,� ft. ft. 5
`u i,I F-0r.a 21.REMARKS A 1
County Parcel Identification No.(PIN) j
2922
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification' �1rQ/Lj0G wV(/f{�
N W e�_
6.Is(are)the well(s) Permanent or 13Temporary 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: ®Yes or 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 I 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: (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: 3 (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
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: f/Z tIZ 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: �r 1636 Mail Service Center,Raleigh,NC 27699-1636
/13a.Yield(gpm) 0 Method of test: J 24.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: d 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