GW1-2022-05760_Well Construction - GW1_20220615

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14:wATERZONES.
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
2080-A _ I
p d ft. IL C 7 t-6 t
NC Well Contractor Certification Number, I5.OUTER CASING(for multi-cased wells)ORLINER"If [icable)
Aqua Drill, Inc. FROM To DIAMETER TLTLCKNESS MATERIAL
Company Name ft 7 rt 61 le in. - 02,39 ,!/7 tl
,16:UNNER CASING OR TUBING(geothermal closed400
2.Well Construction Permit#:G�% FROM To DIAMETER TMHECKNESS MATERIAL
List all applicable well construction permits ti.e.UIC,County,State,Variance,etc.) ft. ft In.
3.Well Use(check well use): fL ft in.
Water Supply Well: 17.FRO 1 SCREEN TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipaVPubhc ft It. in.
Geothermal(Heating/Cooling Supply) 2rResidential Water Supply(single) ft. ft in
IndustriaUCommercial DResidential Water Supply(shared) 18:GROUT.
i.hrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D tt. ft
Monitoring ORecovery ft. ft.
Injection Well:
Aquifer ft. ft
A Recharge o Z��� ` E fs✓®�1+1 a�L
q arge Grotmdwater Remediation 19.SAND/GRAVEL PACK`if a licable
Aquifer Storage and Recovery [ISalinity Barrier FROM To MATERIAL I EMPLACEMENTMErROD
Aquifer Test IOStormwater Drainage ft., ft
Experimental Technology 0Subsidence Control ft. ft
Geothermal(Closed Loop) OTracer 20.bRILYINGLOG attach additional sheets ifnecessa "
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION [n[oG dnrdness soiUroxkyp
0
a rnia size,etc
ft: it /l
4.Date Well(s)Completed: Z'? - z WeU M# ft. ft 7,5AAjd oC — G1
5a.Well Location: ft: u —fL
r
fL ft
Facility/OwnetName Facility ID#(ifapplicable) tt• ft.
tA 1AA ' ` ft.. ft.
( Physical Address,City,and Zip N C 9! ft ft
1 ' tom QJ� O` 21.REMARKS
Conn 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:
N Q�
6.Is(are)the well(s)i�Permanent or OTemporary W Sguature�e of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes. or 4gfNo with 15A NCAC 02C.0100 or NSA 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 ofthis reco d has bean provided to the well owner.
repair under#21 remarks section or on the back of thisform
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 addition y i e details or well
construction only 1 GW-1 is needed Indicate TOTAL NUMBER of wells Boa details. You may also attach additional p h,. s�°a
drilled: C� SUBMITTAL INSTRUCTIONS "IN
9.Total well depth below land surface:. t (ft-) 24a..For All Wells: Submit this form within 30 days of coVmpTetidn
For multiple wells list all depths if different(exanple-3@200'and 2@100) construction to the following.
10.Static water level below top of casing: 6 (ft
IJwvater level is above casing use"+" ) Division of Water Resources;Inform�Ylgly�,
1617 Mail Service Center,Raleigh,NC BUMP, IUM
11.Borehole diameter. (in.) 24b.For Infection 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: 4f g (Z I J
(Le.auger,rotary,cable,direct push,eta) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 1 �' 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: Amount: d 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