GW1-2022-06024_Well Construction - GW1_20220621

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name . o k- q L ft
2080-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multitased welts OR LINER d a Gcable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
k. ft s in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#•`/ �� b C/Z 34I OM TO DIAMETER THICIINESS MATERIAL
List all applicable well construction permits ri.e.UIC County.State,Variance,etc..) in
in.
3.Well Use(check well use):
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE THI('KNESS MATERIAL
Agricultural [3MtmicipaVPublic ft. ft in.
-_ Geothermal(Heating/Cooling Supply)�ElLesidential Water Supply(single) k. ft
Industrial/Commercial Residential Water Supply(shared) 1g.GROUT
hrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: fr. Q k. .eM J
Monitoring DRecovery ft. ft.
Injection Well: ft g,
Aquifer RechargeGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery O'.Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [DStormwater Drainage ft. k. —
Experimental Technology Subsidence Control fr fr
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if nee
To T DESCRIPTION tyM
Geothermal eating/Coolin RetReturn) Other(explain under#21 Rem ft 2-arks) EOM a Nx.
�/ fr. 2 C1OT
2 (otor,hardness saiVrack
4.Date Well(s)Completed: well ID4 f7 k. ft v
j t
5a Well Location: k f ft / C t e
ft. fr.
Facility/Owner Name =` Facility ID#(if applicable) ft. ft.
13 �i Icy -�- U�r� 4.Ay,r8rJ_�
Physi I Address,City,a Zip ft. ft
n/ 21.REMARKS
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:
N W
6.Is(are)the well(s ermanent or Temporary Signature of Certified Well Contractor Date
By signing this form.I hereby cervfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes ordNo with 15A NCAC 02C.0100 or 15A 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#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: CC SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ! �Jr_ (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'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 is above casing,use.'+- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For luiection 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: ,,I(Z'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 27699-1636
13a.Yield(gpm) Method of test: t C 11 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 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