GW1-2022-05299_Well Construction - GW1_20220526

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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 3 w16Ft' 36 f fL 3 7 p,rn'
EL ft.NC Well Contractor Certification Number
is.OUTER CASING for multi- Ld Wells)'OR LINER ,1 a livable'
Aqua Drill, Inc. FROM TO DIMIEIF,R THICKNESS 1ATERIAL
Company Name 0 ft. _20 fL 6-� In. :5 LD l .2 f �t W r t✓
`�� e'� 16:INNER-CASING'ORTUBING eothermal'closed-loop),
,
2.Well Construction Permit#• J `!S FROM TO DIAMETER THICKNESS MATERUL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) % fL in.
3.Well Use(check well use): ft. tL io.
Water Supply Well: 17.SCREEN
_ FROM TO DiAMEfER SLOTSI'LE THICKNESS MAIL+'RIAL
Agricultural O.MunicipaLTublic ft• ft in.
Geothermal(HeatinglCooling Supply) esidenGal Water Supply(single) ft fL
Industrial/Commercial [3Residential Water Supply(shared) 18.GROUT> ..
hTi ation FROM TO MATERIAL EMPLACEMENT METHOn&AMOUNT
Non-Water Supply Well:
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.Aquifer Recharge OGroundwater Remediation
.19:SAND/GRAVEL PACK if a livable
Aquifer Storage and Recovery EISalinityBarrier FROM TO MATERIAL EMPLACEKENTMETHOD
Aquifer Test E)StormwatetDrainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
i'Geothennal(Closed Loop) DTracer 20:DRILLLNGLOG attach.additIonal-srieetsifitecessa
rl Geothermal(Heating/Cooliti Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,wiltrocktype,gmin sae,etc)
y ft. fL �
4.Date Well(s)Completed:C _ ! -� Well ID# ft. It.
5a.Well Location: fL ft.
ft. &
Facility/OwnerN`aame /1-/e Facility l�D#/(ifapplliicabblle) R R
J �57 fV 66` ft. it.
Physical Address,City,an Z' M fL
21.REMARKS
County Parcel Identification No.(PIN) MAY 2
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(.1evermanent or OTemporary Signature of Certified Well Contractor Date G—`
By signing this fortrr,I hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes oroka with 15,4 NCAC 02C.0100 or 15,4 NCAC 02C.0200[Yell Construction Standards and drat a
If this is a repair,fall out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair wider#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:
/��
9.Total well depth below land surface: SUBMITTAL INSTRUCTIONS
c`l (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3Q20000'and 1Q1001 construction to the following
10.Static water level below top of casing: �v (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use""+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
�] ii above,also submit one co of this form within 30 days of completion of well
12.Well construction method: i/z- CJ7 t j copy y
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) y Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one!co of this form within 30 days
type:. 1-IT/! [� copy y of
]3b.Disinfection e: Amount:� � completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department ofEnvironmentat Quality-Division of Water Resources Revised 2-22-2016