GW1-2021-00514_Well Construction - GW1_20210215

�.� Print Form.
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well
Contractor Information:
Gar) Thompson 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4418-A i I C, ft I iq ft ko S G �,
ft.
Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)'OR LWER ifa Gcable -
Aqua Drill, Inc. FROM I TO DIAMETER THICKNESS MATERIAL
v ft. ft- �a:z 7 / i1! G1.{D
Company Name ,
16:INNER CASING OR TUBING''eothermal"closed-loo
2.Well Construction Permit#: 3�t(3 :.tee �N �-� FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) It. ft. 'n
3.Well Use(check well use): fr. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural EIM tcipal/Public U ft. ft. in.
Geothermal(Heating/Cooling Supply) : esidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irfl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: It- -1-1 t�C , t
Monitoring E3Recovery ft. ft.
' -W_ Injection Well:
Aquifer Recharge Groundwater Remediation
19.-SAND/GRAVEL PACK'ifa Iicab]C .
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test ®IStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional'sheets if necessary)'
Geothermal(Heating/Cooling Coolin Return) FROM TO DESCRIPTION color,hardness,soilfrock e, rain size,etc.
( g/ g ) Other(explain tinder#21 Remarks) ft. It.
0
or
4.Date Well(s)Completed: -�Z l Well ID# +S IL 15 ft. b>+ a
5a.Well Location: ] 35' It.
t 5, ft.
� Cot a:�
)e N(%0 tr 1 4Vyt 4C,S S ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ex ly
ft. ' tr ft. 1 G
i °t3� PAYIve PA. �IAI.► 'c��$I,b Gtt�.ran� W c ft. ft. '
Physical Address,City,and Zip -�.t Z'�3 ft. It.
A)Am 0r4--p, ��� 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) r Certification:
6.Is(are)the well(s)�rmanent or OTemporary ^QTkn of ertified Well Contractor Date
� t t 1 [, By sign lts form,I hereby certify that the well(s)was(were)constructed in accordance
7.IS this a repair to an existing well DYes or O"'T ` l�(�fMVt'AC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature f�$Qr,2c't�py of this record has been provided to the well owner.
repair under#2/remarks section or on the back of this form. �t �,R S?CY23`.`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 I 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 ifdifferent(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,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4. (in.) 24b.For Injection Wells: 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: M4.1 V A. / 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) ( JT Method of test: GAkI•��i"�e 24c.For Water Supply&Injection 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: 0,,p Amount: l t/o�� 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