GW1-2021-03463_Well Construction - GW1_20210607

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WELL CONSTRUCTION RECORD Q jM-1) For Intemal Use Only:
1.Well Contractor Information:
Gary Thompson 14 WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft.
4418-A
ft. ft.
NC Well Contractor Certification Number 15.'OUTER CASING.for multi-cased'wells OR LINER tf a livable
Aqua Drill, Inc. FROM TO DIAMETER TtI1CIQYESS I MATERIAL
ft.Company Name
A141 ft. (a,Zr in. S d P X` P U C
•-� 46r1NNER CASING OR 1UBING e6thermal dosed-too
2.Well Construction Permit#: t,Cd`d C��(.c)1�N��O 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. fa in•
77.;SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft.
Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft. ft. in,
Industrial/Commercial Residential Water Supply(shared)
18:'GROUT
Irrigation FROM TO MATERIAL- EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a ft. .Z ft Cc4" 4
Monitoring pRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation 19 SAND/GRAVEL<PACK if ii "llceble
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal MeatinglCooling Return Other(explain under#21 Remarks)^ FROM TO DESCRIPTION color,hardness,soflf—k type,grain size,etc.
C7 ft. (g— & p
4.Date Well(s)Completed: S'Lf-�.1 Well ID# I f' 3S ft.
ft. it
17
5a.Well Location: `{ Ca �
:
ft.
Facility/Owner Name Facility
�� /Faaci�lity D#/�(if applicable).{ ft. ft.
7� � \Z ��►�L'w �f'1�R1 io ht 7.1J�l� ft. ft
Physical Address,City,and Zip ft. ft
CJ4�f!�)•� 21.RENIARKS
County Parcel Identification No.(PIN) I6f0_rrr,_3t_io_nPrcCeS9In9 Unit i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat/long is sufficient) 22.Certification:
360 1 J'43, X72" N �!®a n l �� 5: �r'4a �� W
6.Is(are)the well(s) rmanent or Temporary Si re ore6ffed Well Contractor 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: E3Yes or E3&o 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-i is needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled' r� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 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 1@100) construction to the following:
10.Static water level below top of casing: J S (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
` above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: t'"et6a.y 14 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) IVY- Method of test: Cb16-.3 r'YrG 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: IL � t�� Amount: �'/L completion of.well construction tol the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016