GW1-2021-05438_Well Construction - GW1_20210503

':. Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King VY 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
Zoso-A MA'( x 3 202�
fO ft. It C' /
NC Well Contractor Certification Number 1Ji11� J [J i
} 1001asSIB� 15.OUTER CASING for multi-cased wells OR:LINER if a licable
Aqua Drill, Inc. I;tr J11M��C J�J���� FROM TO DIAMETER THICKNESS MATERIAL.
1 1-` ft. ft. �� in. �/ C
Company Name ^ t
16.INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL,
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. rt. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SL.OTSIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft, ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: co an ft. It-
t h`
Monitoring ElRecovery ft. ft.
Injection Well:
1 Aquifer Recharge 13Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery EI Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if.necessa
Geothermal(Heating/CoolingReturn) I Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiVrocktype, Mtn size,etc.
ft. < ft. �o
4.Date Well(s)Completed 4 ;z Well ID# ft. oft-
C 1/
5a.Well Location: O ft. t. !UG rZ f9y9 f}G
\ ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
� ?7 ft. rt.
physical Address,City,and Zip yi f G� ft ft
` �/)1 ` ) I O 21.REMARKS
Couunn/ty�f/, 1 Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification: J
N W
Si re of Certified Well Contractor
6.IS(ar¢)the well(SPermanent or Temporary 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: [3Yes or No with ISA 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.
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: qq SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: t>�o� (fW 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3`@200'and 2@I00� construction to the following:
10.Static water level below top of casing: Sr 0 (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: 6
` (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: above,also submit one copy of this form within 30 days of completion of well
1 2 12-I
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: G 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) y Method of test: J 24c.For Water Supply&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: Amount- ®2- completion of well construction to the county health department of the county
where constructed. {
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources,:: Revised 2-22-2016