GW1-2021-00288_Well Construction - GW1_20210127

WELL CONST'RUCT'ION RECORD(GW-1) For Internal Use Only: \
1.Well Contractor Information:
Gary.Thompson 14:WATER zoNEs
WellCoatrnetorNamc FROM TO I DFSCRJPn0N
4418-A l os- fa i o-7 fL fo Sd pn^
NC Well Contractor Certification N=bc
15:OUTER CASING for malti-cased:we& OR LINER a`Gcable
Aqua Drill, Inc. FRUM I TO D1AMEFER THIcwms UA
ft_Company Name �(Y. ft (ot _I in. 1/if GMU 1 byY
16.:11VNER CASING OR TUBlriG therntat closed+Ion
2-Well Construction Permit#: 4009 w e.L Zt5 FROM To D14METER TMCMiMS I MATEFIAL
List all applicable cell construction permits t?e.U1C.Cmmry,Stag iroriance,etc) fL iL fir.
3.Well Use(check well use): R ice.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE TffiCBNFSS IATERiAL
Agricultural �Munioipal/Publio �
Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft In.tti ft in.
IndustriaUCommercial E31tesidential Water Supply(shared) 1&GROITf
Irrigation FROM TO MATERIAL + EK1PLACEblEWMMUoD&H T1-0U
Non-Water Supply Weil:- ft 23 tc
Monitoring Clitecovery ft. ft,
Injection Well:
. g tZ
[Aquifer
fer-Recharge []Groundwater Remedietion
fer Storage and Recovery [3Salinity Barrier 1F9ROMAND/GR VEL PACK'hi a EMPLAC6I UNirmEmon
Test [3Stomiwater Drainage &
rimental Technology [3Subsidence Control f4 &
hermal,(CiosedLoop) Tracer 20.DRII.LINGLOG attachadditionaisheersifnece4sarvhermal(Heating/Cooling Berton) Other( lain under#21 Remarl�) FRon1 To DESCRlrrION color giant saWrock a sortie.
O ft
4.Date Well(s)Completed: �_ L Well ID# )v iZ — fr
�h1. wrY 0o AOk wS o
5a.Well Location: f4 R' bLk B,
Facilityl0wner Nam ��Shy Facility IDS(ifapplic1abte))t S(I-� 7� J ly G is
L i J y 9 r'eJ Ak'� S 111Q 't-L'�5 L lewIt y i�b ft i^!
Physical Address,City,and Zip Cyt�gkprv�NC-y1157) z" a :==.q `i
r E-�m At u C � flO�L 21.REMARKS q
County Parcel Identification No.(PIN) J A N [r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees.
(ifwelt field,one lallong is sufficient) 22.Cerdrrcation:
?S°S-8 '3 ,OS Lit N �7 9 0 f 91 €
w
6.Is(are)the well(s)OPermauent or OTemporary Signer re of C ' ed Well Co tractor Date
By signing this form.1 hereby—try drat the trell(s)eras(ireral constructed in accordance
7.Is this a repair to an existing well: []Yes or QNo with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 i dl Consirncuon Smrtdan&and that a
If lilts is a repain fill act ktrosm,sell construction information andexplain the nature of the copy of this recordhas beenprovidedto the uell miner.
repair under 921 reniarkrsection or on tke backoftldsform. 23.Site diagram or additional well details.
8.For GeoprobcIDPT 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.OW t is needed. Indicate TOTAL NUMBER of weils construction details. You may also attach additional pages if necessary. .
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 24a. For All Weill:. Submit this font within 30 days of completion of%yell
For nudiiple uvils list all depths ifdrfferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: Division of Water Resources,Information Processing Unit,
Ifn+orer level is above casing,are"_" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 61 (in.) 24b.For Intecdon Wells: In addition to sending the form to the address in 24a
12.Well construction method. M 4yr
above,also submit one copy of this form within 30 days of completion of well
(ie.auger,rotary.cable,direct push.ere) construction to the fallowing:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
-13a.Yield(gpm) Sa Method of test: cp PcL . I M e- 24c.For Water Supply&Infection Wells: In addition to sending.the form to
�{ of o the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 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 Aster Resources Revised 2-22-2016