GW1-2022-05019_Well Construction - GW1_20220519

Print Form
WELL CONSTRUCTION RECORD(GW-1) For Intelltal Use Only:
1.Well Contractor Information:
-Chris King 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A J lI J8i fb -r/�
ft, ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells ORLINER tf a livable
Aqua Drill, Inc. FROM To I DUa TER I THICKNESS nfATERrAL
ft. /!Gj ft.
t �S / in. Q��
Company Name CG
`/J 2 �_1 f / 16.INNER CASING OR TUBING(mother mal dosed400
2.Well Construction Permit#: <)� - ( FROM TO DLINIETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,&atg Variance,etc.) ft. ft.
3.Well Use(check well use): ft. ft
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS AIA17IAL
Agricultural DMunicipal/Public ft. & in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18;:GROUT
Irrl ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft - d ft. , Z J
Monitoring DRecovery ft ft.
Injection Well: ft ft
Aquifer Recharge DGroandwater Remediation
�,�' 19.SAND/GRAVEL-PACK d'a lieable "
^i Aquifer Storage and Recovery Y Salinity Barrier FROM To I MATERIAL` E4IPLACEMENTMETHOD
Aquifer Tcst OStormwater Drainage ft. ft.
D. Experimental Technology OSubsidence Control ft. ft.
,Geothermal(Closed Loop) OTracer 20:DRILLING LOG attach additional sheets if necessary)
Gcothermal(Heating(Cooling Retain) FROM TO DESCRIPTI(N color hardness soillmek a rain sac,eta)
,/ g ) ; Other(explain under#21 Remarks)
ft. ft Z (f!_
4.Date Well(s)Completed --",?—Well ID# ft. 5 r� ft. S) ,l f J
5a.We1l.Location:
ft. It.
Facility/Owner Name Facility ID#(if applicable) ft. ft
p2 J U S lZ Cd �7 t� !Z C !�-/Zi��+✓�b'1 �3 • ft. ft K d r�.-,i�
Physical Address,City,and Zip ��^ ft. ft
MAY
A/�"'7_11jue•C J 2L REMRKSA '
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 wells) Permanent or OTemporary 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: Dyes o o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Conshucliion Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the ropy of this record has been provided to the well mvner%
repair wider 921 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: aft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For mulaple wells list all depths if different(example-3@2000'and 2@100) construction to the following:
10.Static water level below top of casing: J v aft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use
11.Borehole diameter: �"+"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
Y (in.) 24h.For Injection 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- C.t IZ r I L construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) arm Method of test:15§0 h A— 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:_1ya G- Amount: ( 6 2 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