GW1-2022-08952_Well Construction - GW1_20220919

Print Form 4 `:
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: —-
1.Well Contractor Information:
Chris King 14.WATER-ZONES_ i. .
: ...
Well Contractor Name FROM TO DESCRIPTION
2080-A ..2 ft' 2 ft
ft. ft. ✓
NC Well Contractor Certification Number
15 OUTM,CASING focmulti-easidi eIIs:ORLINER.lfmf Gcable
Aqua Drill, Inc. FROM TO DIMIETER ; THICKNESS MATERIAL
Company Name 0 ft' ft. 4p C 1 m
J
5P14 2 1. I C
�16.'INNER'CASINGOR TUBING" 'etitbermal'dosed loo =o-=i,.a
2.Well Construction.Permit#: j l 26[)6 -- 'b 13 FROM To D1AntE'M THICKNESS I MATERL41,
List all applicable.uell cmutruciion permits(Le UIC,Count};State,Yariancg etc) ft. in
3.Well Use(check well use): ft. ft. in.
i
Water Supply Well: .-I SCREEN..
FROM TO DIAMETER I SLOT SIZE I T FIT CKNESS MATERIAL
Agricultural [3Mtmicipal/Public ft fL in.
Geothermal(Heating/COOling Supply) ogeSidential Water Supply(single) ft ft
Indu"striaUCommer W DResidential Water Supply(shared)
18r.GRODT
. : n- aOR FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: � ft � ft. � 1�1 k;
Monitoring Recovery f- T
Injection'Well:
A tfer Rech ft ft
qu arge []Groundwater
Aquifer Storage and Recovery Salini Barrier 19 SAND/GRAVELFAC&da liable":: :. ...:.
ty FROM TO I MATERIAL yEMPLACEMEI\TMETHOD
Aquifer Test C)SWUnwaterDrainage ft. ft
Experimental Technology oSubsidence Control ft ft
Geothermal(Closed Loop) E3Tracer
20 DRiL-LINGLOG:(attach additional'sh'eets irnecessa )
- Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) I FRonI To DESCRIPTION color hardness soiFruck rain sae etc
ft. ft ��(
_41
4.Date Well(s)Completed: —� �Rrpg]D# ft; 'O f" 5 A d4 f d
fZ C
5a.Well Location: c) fa hi C, .Cs)Z SQ ru),f r
ft. ft.
Facility/Owner Name Facility IDli(ifyappricable) ft: ft.
Ole
0 i�5c1 e �l ft & Ci
Physical Address,City,and Zip % ft
xi
County Parcel Identification No.(PIN) J
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification:
6.Is(are)the well(s) Rermanent or OTemporary SigmEtre of'Certified Well Con of Bate
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes orIo with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Net/Construction Standards and that a
Ifthis is a repair,fill out loiown well construction information mid explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under#11 remaiks section or on this 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:__ 2 �'1 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiffererrt(example-3Qr2�00'aria 2Q100) construction to the following
S0 f Static water level below top, using: (ft) Division of Water Resources;Information Process' Unit,
Ijzvater level is above casing,use"+" Illg t,
G 1617 Mail Service Ceiter,Raleigh,NC 27699-1617
11.Borehole diameter: fin.) 24b.For Iniection Weill: 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: Z .(Le-auge,rotary,cable,direet push,etc-) construction to the following
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m i
(gp )_ Method of test: 1 24c.For Water Supply&Iniection Wells: In addition to sending the form to
A the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 1 Q 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