GW1-2022-03843_Well Construction - GW1_20220331

Rant Form
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 .50m ft a G,/'
ft. fL
NC Well Contractor Certification Number 15.OUTER CASING for I!!I axed wells bR LINER`if a Gcable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name a ft. ® ft16 Vef, in. 50,12 PIV C
_ '16.INNER CASING OR TUBING eothermal closed loo 'z
N N i� O r
2.Well Construction Permit#: 9 7 Ty 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. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public ft. It. in.
:',)Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft, in.
Industrial/Commercial OResidential Water Supply(shared) IS.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. fL
Monitoring _ ;Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 13Groundwater Remediation
19:SAND/GRAVEL-PACK if.a licatile ?�,. ,
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. fL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if nemssa
Geothermal(Heatin CooliII Retum) Other(e lain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiltrock e, roan size etc
G '�ff O ft. / fL e 60
4.Date Well(s)Completed: — 2'"�'Vell ID# ft. fL Sint QDCL 1R',U ci
5a.Well Location:
fL fL
Facility/Owner Name / Facility ID#(if applicable) ft• IL
51 [sR�'L'iUS �U1ZA N o� ft. ft.
Physical Address,City,and Zip x 7 SS ft. fL
Gt vi+�J-o2 REMARKS
c� ' �
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s) rmanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or [3No 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. `
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: SUBMTTTAL INSTRUCTIONS
9.Total well depth below land surface: /el— 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing: 30 (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: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
ll above,also submit one copy of this form within 30 days of completion of well
'e
12.Well construction method:_ i"�A tJ iz l I 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) Q Method of test: 1�YI 24c.For Water Supply&Iniection Wells: In addition to sending the form to
1 V//yy Z the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: / Amount: 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