GW1-2022-06029_Well Construction - GW1_20220621

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1_Well Contractor Information:
Chris King I4:.WAMR:Z0NES-,.:
WellConttactorName FROM TO DESCRIPTION
2080-A Cato ftIt.
t/ I i
��-ft. ft• it
NC Well Contractor Certification Number 15.OUTER`CASWG fdi multi-msed welliV J INER`Ifa livable'... -
Aqua Drill, Inc.. FROM To D�AMMEEpl•EER THICKNESS MATERiLII.
Company Name ft ft G J�D m f 7S +`
`�f �A -A HWER�CASING'OR.TUBING(e eitherinal;closeddoo
2.Well Construction Permit# I C hf z l� _I_� FROM TO DIAMUER THICKNESS MATERIAL ~
List all applicable welf construction permits(t:e.UIC,County,State,VartancA eta) ft. ft in.
3.Well Use(check well use): ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public fL.1 ft in.
Geothermal(Heating/Cooling Supply) ff e.idential Water Supply(single)
ft. ft. iu.
: IndustriaVCommercial DResidential Water Supply(shared)
1&:GROUT ;
irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft- AD 'L �d h
--Monitoring. ORecovery fL ft
Injection Well:
ft. ft
Aquifer Recharge [3Groundwater Remediation
'19.SAND/GRAVELrACK da Gcable
Aquifer Storage and Recovery . Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStomrwater Drainage fL IL
Experimental Technology OSubsidence Control ft it,
Geothermal(Closed Loop) Tracer _20 DRILLINGLOG attach additional sheets ifaems
Geothermal(Heating/Cooling Return) nOther(explain under#{21 Remarks) Vft.
TO DESCRIPTION color,hardness,solOrock a rain size,etc.
fL •' 1
ff C
4.Date Well(s)completed: 2— well Ew k r' I Qft. ft. 004— —
Sa.Well Location: t- �' . 1V � e11 ill j
ft
3 Facility/Owner Name Facility I)D#(if applicable) fL ft
1�1-.� L
1-7
Phy'cal Address,City,and Zr
pl ft ft
fy1m � "21.REMARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,,• � •._
(ifwell field,one lat/long is sufficient) 22.CertiticatioR Q•`,: `i rr t;i
�1 r
lv W _
6.Is are the wells e r � � 6 3`__ rman ent or Te ora Si of Certified WellContractoP Date
By signing this form,I hereby certify that the we11(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or E f se with ISA NCAC 02C.0100 or 15ANCAC 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 retard has been provided to the well owner,
repair under#21 remarks section or on the back ofthirform. 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 listall depths if&ferent(example-3@200'and 2@100) 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: Cf3 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
e j /f above;also submit one copy of this form within 30 days of completion of well
12.Well construction method: ) � C lZ i f!
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: zg�I=t'�- 24c.For Water SuDDIV&Infection Wells: In addition to sending the form to
�g the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: �T Amount- Z completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016