GW1-2022-06025_Well Construction - GW1_20220621

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.wATERzONEs
FROM TO DESCRIPTION
Well ContractorName g ! j g, 3 !C3 t t VIL
2080-A no tt. (q) tt.
t.
NC Well Contractor Certification Number .S.'OUTERCASING for'multicasedsvells'OR-LINER(ifa `Unable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIALlt.
L ft. 6 S/ in. f 3 O A h
Company Name (�, /J� 2 :16.INNER CASINGORTUBING eotheruialclosed-loo
2.Well Construction Permit#:�"/ �'V--� �� ^`�- FROM TO DIAMETER THICIINEss MATERIAL
List all applicable well construction permits#.e.UIC,County,State.Variance,eta) tt ft in
ft �•
3.Well Use(check well use): ft.
17:;SCREEN-
Water Supply Well: FROM TO DIAMETER SLOT SIZE TmCKNFSS MATERIAL
:.:Agricultural DMmricipal/Public
Geothermal(Reating(Cooling Supply) esidential Water Supply(single) m f
lndusWal/COmmercial Olkesidential Water Supply(shared) 18i:GR0UT
hTi lion FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O tt U ft. di7x2& f
Monitoring fD—Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge iOGroundwater Remediation
,19SAND/GRAVELPACK ifa'linable
_ Aquifer Storage and RecoverySalinity BaaiCr FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwatr;r Drainage ft ft
Experimental Technology OSubsidence Control ft. f,
Geothermal(Closed Loop) OTraeer '.20.DRILLINGLOG attachadditionalvheetsifnecess
FROM TO DESCRIPTION coW,hardness,suit/mck t rain size.etc.)
Geothermal(Hcating(Cooling Return) Other(explain under#21 Remarks) ft- e-d
to
4.Date Well(s)Completed6—1 �z Well W# - L ft- g ft. 5A
5a.Well Location:
M ft.
Facility/OwnerrNa�me Facility ID#(if applicable) R ft.
O f A,� (.g�1CAI el �e[ZW(qo5,A J(, (f.-IHY�(1Lv fL ft.'T— ft. ft
Physical Address,City;and Zrp t`r•>� �_ r'
21'.REMARKS
County Parcel Identification No.(PIN) I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweR field,one lat/longissufficient) 22.Certification:
N W lr.i ti
6.Is(are)the well(s) Permanent or OTemporary Signature of Certified Well Coutfactor Date
By signing this form,I hereby cerlify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or 6N. with 15A'NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known ive/l construction information and explain the nature ojthe copy ojthic 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: f— t] (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200''aand 2@100) construction to the following:
10.Static water level below top of casing: .90 (ft-) Division of Water Resources,Information Processing Unit,
lfwater level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in-) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
1 .Z G l�* above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1 l 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) Method of test: I �-f 24c.For Water Supply&Iniection 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: UTIJ Amount: 9 © 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