GW1-2022-06903_Well Construction - GW1_20220718

Prinf 17,crrin,
WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only.
1.Well Contractor Information:
Chris King
14.WATER•ZONES,! A
Well Contractor Name FROM TO DESCRIPTION
2080-A W61'. I IL
ft. %
NC Well Contractor Certification Number
:15.OUTERCASING Mr ifialti-cased,wells)OR LINER rif itillivable
Aqua Drill, Inc. FROM TO I DIAMETER THICKNESS MATERIAL
in.
Company Name K4 5- ft. 1/1
_16ANNEICCASING
2.Well Construction Permit#:Z67-1,JQ FROM TO DIAMETER, THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance etc.) ft ft. il in.
3.Well Use(check well use): ft ft. in.
Water SupplyWell:
DIAMETER IETER i I SLOT SUE THICRWESS MATERIAL
DMunicipaMblic fL Imt:
:IGeothermal,(Hcating(Cooling Supply) residential Water Supply(single)
:)IndustriaYCommercial E3Residential Water Supply(shared) fL ft..
;19.GROUT
'11nigation FROM i TO MATERIAL I EMPLACEMENT METHOD- :&AMOUNT
Non-Water Supply Well: ft. %
hMonitoring E)Rccovery ftft.
I Injection Well:
ft. ft.
AquiferRecharge Groundwater Remediation
DAquifer Storage and Recovery oSalinity Barrier 19.`SANDIGRAVEEXACK if applicablel
FROM TO MATERIAL EMPLACEMENT METHOD
:3Aquifbr Test Stormwater Drainage
:]Experimental Technology
E]Subsidence Control ft.
:)Geothermal(Closed Loop) OTracer 20.DRILLING LOG.(atta 'additibriatsheetslif necessaxy)-.-
Geothermal(Heating/Cooling Return) r-10ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiltrocktyp4 grain size,etc.)
ft. SOl
4.Date Well(s)Completed./_: Well ID#
ft. fL
:5a.Well Location:
'9 cis
ft.
Fa'cility/Owner Name Facility M#(if applicable) ft. fL
S;20 d
Ali/c V-U ,(j ft. V tLq L)
Physical Address,City,and Zip ft. ft.
5A PJ -21'.'RENIARIC5 14 2090
County Parcel Identification No.(PIN)
PRO,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
W
6.ls(am)the wellwo-manent or OTemporary Signature of Certified Well Cont for Date
By signing this form,I hereby certi thilt the weff(s)was(were)constructed aco YY - in c rdance
7.Is this a repair to an existing well: Oyes or No with ISA NCACO2C.0100 or ISANCACO2C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has beers provided to the well owner.
repair under#21 remarks section or an the bad-of this farm- il
23.Site diagram or additional well I'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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
-
SUBAHTTAL INSTRUCTIONS
9.Total well depth below land surface:
Tor multiple wells listall depths if different(example-3@200'and 2@100) (N 24a. For All Wells-. Submit this'form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: 60
If water level is above casing,use Division of Water Resources,Information Processing Unit,
1617 Mail Service C�Pt�r,Raleigh,NC 276994 617
11.Borehole diameter.—6 (in.) 24b.For Injection Wells. In addition
ion to sending the form to the address in 24a
12.Well construction method: i 12 dai above,also submit one copy of thi's form within 30 days of completion of well
(Le.-get,rotary,cable,direct push,etc.) construction to the following:
FOR WATER S Division of Water Resources,Underground Injection Control Program,
SUPPLY WELLS ONLY: 1636 Marl Service Cente'r,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test. 24c.For Water For�ter Su ly&Infection!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. completion of well construction to I
where constructed. the county health department of the county
I
Form GW-1 North Carolina Departinent of Environmental Quality-Division of Water Resources Revised 2-22-2016