GW1-2022-05021_Well Construction - GW1_20220519

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
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FROM TO DESCRIPTION
Well Contractor Name 0 fo ` 6 i
2080-A
fL 3U 6—"A/vl
NC Well Contractor Certification Number 15.OUTERCASING(for multi,cased"wells OR.LINER d a licable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 tt. (,.� fL CJ%%S' in. , d� &,411
Company Name
�(L� 1 16.INNER CASING OR TUBING(eotl ertnaCdosed-loot
2.Well Construction Permit#:.. - U `(Z(-2J Lpt I FROM To DIAMETER TIlICI4NESs MATERLAL
List all applicable well construction permits(.e.UIC,County,tState,Variance,etc.) ft. fL an.
3.Well Use(check well use): ft. ft io.
Water Supply Well: 176 SCREEN.
FROM TO. DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. fL in,
0,
Geothermal(Reating/Cooling Supply) esidential Water Supply(single) fL % in•
4ndustrial/Commercial DResidential Water Supply(shared) 18.GROUT
IrT't ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL ft. St? l
Monitoring DRecovery ft. fL
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL"PACK if applicable) '
Aquifer Storage and Recovery Ql Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Ql Stormwater Drainage ft, fL
Experimental Technology OSubsidence Control fL ft.
20:DRILLING LOG attach additionalalieets if necessar
Geothermal(Closed Loop) QlTiacer
FROM TO DESCRIPTION color,hardness wiffmck type,grain size,eta
Geothermal(fleating/Cooling Return) i Other(explain under#21 Remarks)' "' ft-
IL
4.Date Welt(s)Completed:. / -a Well ED# h() ft. S-Y ft' s t
Sa.Well Location: r ft. fL
fL ft
Facility/Owner Name 9 ` - Facility ID#(ifapplicable) ft" ft. \`"A °� 3
0 Pi4-1yu C- R O `� Y�M - C\ , ft. fL 'yl
Physical Address,City,and Zip ft. ft
fJ �11r:1� 21.REMARKS
County Parcel Identification No.(1`II1)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: ..77
r �y
N W
6.Is(are)the well(s) ermanent or OTemporary Signature of Certified Well Contractor Date 1
By signing this form,I hereby certify that the ivell(s)ivas(were)constructed in accordance
7.Is this a repair to an existing well: OYes or ffNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
If this is a repair,fell out known well construction information and explain the nature of the cop),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: y SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: gS— (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii different(example-3@200'and 2Q1001 construction to the following:
10.Static water level below top of casing: �� (ft) Division of Water Resources,Information Processing Unit,
If water level fs above casing,rise"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.'Fdr Injection Wells: In addition to sending the form to the address in 24a
J l� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: d��/Z G/�l/ 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 276994636
13a.Yield(gpm) �� Method of test: J 24c.For Water SuDDly&Injection Wells: In addition to sending the form to
/E o the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: >? /'a Amount: El 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