GW1-2022-06030_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.,. ;
WellContractorName FROM TO DESCRIPTION
2080-A f d� ,
ft It
NC Well Contractor Certification Number :15.'OUTER CASING(for multi-casedmMus)ORLiNER ifs licable
Aqua Drill, Inc. FROM I TO DIAMETER THICKNESS MATERIAL
O ft 9 ft. /�e in.
Company Name l.�
��f j^f •:FROM ER CASING'OR TUBING eothermal'closed-too
2.Well Construction Permit#' /b(�J (.�-U FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits C.e.WC,County,State,Variance,etc.) ft ft in. IS
3.Well Use(check well use): ft, ft in.
Water Supply Well- 17[SCREEN.FROM TO DIAMETER' SLOT SIZE THTCKNESS MATERIAL
Agricultural Mtmicipal/Public g. ft in.
Geothermal(Heating/Cooling Supply)! Residential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared)
`18-GROUT
JErrigatioa FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft
Monitoring i Recovery ft. ft
Injection Well:
ft R
Aquifer Recharge L[]Groundwater Remediation
19:SAA'D/GRAVELPACIC if a'"licahle
Aquifer Storage and Recovery OSanityBarrier FROM To MATERIAL I EMPLACEMENT METHOD
Aquifer Test O Stormwater Drainage ft. ft
Experimental Technology O Subsidence Control & ft
Geothermal(Closed Loop) _. Tracer .20:DMLMG'LOG attach additional sheets ifnecess' '
Geothermal(Ileating/Cooling Return) -_Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltmek in size,etc
/� O fL q
4.Date Well(s)Completed5= ell ID# ft- 79-ft
Sa.Well Location: fr Sr ft !J C
ft. ft�
Facility/Owner Name [Facility ID#(ifapplicable) fL ft. y
Physical Q ddtess,City,and Zip -
A/ / 21'rREMARKS,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient)
22.Certification:
Iv W
6.Is(are)the wells) rmanent or OTemporary Shpiffm ofCcrti6ed We Contractor Date
By signing this form,I hereby cert fy that the we l(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or ONo with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 WL11 Construction Standards and that a
Ifthis is a repair Jill out known well construction Information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair udder#21 remarks section or on the back ofthisform.
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 mahiple wells list all depths ifdifferent(example-3Qa 200'and 2@100) construction to the following:
10.Static water level below top of casing: 3:51 (ft.) Division of Water Resources,Information Processing Unit,
Ifivater level is above casing,use"++" 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 0! (m.) 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
T]2.Well construction method:_ /OJ !�{ j�I 1 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: yC 24c.For Water Supply&Injcetion 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: ()Z 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