GW1-2022-05301_Well Construction - GW1_20220526

Print Form.
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 44.WATER ZONES
FROM TO DESCRIMON
Well Contractor Name g, ft 3 %i
ith
2080-A
176 It. 27) ft. !;z6 t
l n'i
NC Well Connector Certification Number I5:.OUTER CASING for mulfl-cased wells OR LINER if a livable`
Aqua Drill, Inc. FROM TO DiAMETEA THIC[INESS MATERIAL
0 it. cS fL to Aq in. �I>iZ)_ 1 1
Company Name el 4 //� �b� !9 .INNER CASING OR TUBING eothermalclosed=too
2.Well Construction Permit#: e0 `w I", '�-y FROM TO I DIAMETER I THE I MATERIAL
List all applicable well construction permits(Le.UIC,County,State,lrariance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN.
Water Supply Well: FxoM TO I DIAMETER SL01'SIZE TH1C[INESS AfA'fERIAL
Agricultural DMunicipal/Public ft. ft.
`Geothermal(Heating/Cooling Supply) ffXesidentil Water Supply(single) ft ft. in
Industrial/Commercial (DResidential Water Supply(shared) 19.GROUT
IrriQaticn FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
N 12
Non-Water Supply Well: b ft. ft Ceiy1 0
Monitoring ORecovery ft. it.
Injection Well: ft. ft
Aquifer Recharge !Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EdfPLACEItiENT METHOD
Aquifer Test 0 Stormwater Drainage ft. it.
Experimental Technology 0Subsidence Control fL it.
Geothermal(Closed Loop) QlTracer 20.DRILLING LOG attach additional sheets if necessary)'
_ FROM 11 TO DESCRIPTION mfor,hardness,soiYrock type,grain size,etc.
Geothermal(Heating/Cooling Return) i' Other(exTlain
/undder#21 Rem�arjks) ft. it G� �=f
4.Date Well(s)Completed:`S 9'��eil ID# [�`� n y
� � F ft �y7S it h.tlC� G l�
5a.Well Location: 2 94-ft.
ft. fL
Facility/Owner Name J Facility IDN(.igf t
�applicable) ft. f
Physical Address,City,and Zip '17 q 5-5 fL it
21.REitifAM
(!�Oi 1 rf3l2 1 ll
County Parcel Identification No.(PIN) .ry ,J `-ivi
.l ilri i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Cerllfictjtion:
N W
6.Is(are)the well(s) ermanent or OTemporary Sigoatam eCertified Well Contmeto Date
^ By signing this foram,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or VC' with ISA NCAC 02C.0100 or ISA 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 421 remarl5 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 ifnecessary.
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 ifeli ferent(example-3(100'and 2@1000 construction to the following:
10.Static water level below top of casing: (f>) 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: Crn•) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
s ( above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: A 1 Z cl IZ I 1 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 27699-1636
13a.Yield(gpm) J Method of test: 151 RI► 24c.For Water Supply&Iniection Wells: In addition to sending the form'to
� �y the address(es) above, also submit one copy of this form within 30 days of
���-�E-
13b.Disinfection type: � Amount: 9 completion of well construction to the county health department of the county
where constructed.
Farm GW-1 North Carolina Department of Environmental Quality-Division of W ater Resources Revised 2-22-2016