GW1-2021-00352_Well Construction - GW1_20210127

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King .14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
Zoso-A , oF
a trl
ft Q G I i
NC Well Contractor Certification Number ,15.OUTER CASING for multi- edmells OR LINER tf a licable
Aqua Drill, Inc. /FROM TO DIA`MEITER THICKNESS MAT/ER,IAL/
Company Name `—' � v fL 6` �is )Z)„ '//s <-/
�� \ �� ,46.INNER CASING OR TUBING(geothermal closed-loop)'
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(ice e.UIC,County,State,Variance,etc.) ft ft.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural rMunicipal/Public 1 fa fa in•'
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. �•
Industrial/Commercial QIJ Residential Water Supply(shared) 18.GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q fL
Monitoring 13Recovery ft. &
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage ft. &
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach'additional sheets if necessary)
Geothermal(Heating/Cooling Return) 7 Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.
[� ® ft ft. G�f Glr�
4.Date Well(s)Completed:/ —/7 `.2l Well ID# ft' Q ft- �j G (ze-oE
5a.W(ell Location: I� , � ft• Ld�c fi- �/U !z C
Cj'i l ' — �L/9 r&VQ -`s��, ft. ft.
Facility/Owner Name 7 _ / J�► f Facility 1D#(if applicable) P ft. R-
�C P C ��t?/ 4_,/AJ /G7 x lI n d`i ft ft
Physical Address,City,and Zip ;� ft. ft
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latnong is sufficient) 22.Certification:
6.Is(are)the well(s) _ Permanent or OTemporary igna d Wel Cow ctor Date
., 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 ®Yes or No _ with 15A NCAC 02C.0100 or 15A NCAC 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 of+this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
� �, 11 2B"S7te diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the e 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: �/� (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if differeht(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,
Ifwater 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
f� c ( above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:t / b/�2 1 construction to the following:
(i.e.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: /1 24c.For Water Suonly&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: am Amount: 0 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