GW1-2021-03092_Well Construction - GW1_20210622

Prin orm
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Gary Thompson 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 1
`'e"'' �ei p-I✓`'
4418-A
e. tL
NC Well Contractor Certification Number 15.OUTER CASING for multi cased`welis OR.LINER'il'a livable
Aqua Drill, Inc. FROM TO DIAMETER THICKINESS MATERIAL
D fr. Lo ,�" tt 4.>•S in. s xL- Q VL
Company Name 16 INNER CASINGOR TUBING eotbermal:iJosed-loo
2.Well Construction Permit#: 2 LJ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. fL In.
3.Well Use(check well use): ft. fa in.
Water Supply Well: FROME TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft. in,.
Industrial/Commercial Residential Water Supply(shared) IB::GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. _L;V ft ,� l
a�., r
Monitoring 13Recovery ft. %
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/G12AVEL,PACK ifs" "livable '
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) E3Tracer 20.DRILLING LOG attach additional sbeets if necessa
Geothermal eatin C oling Return Other(explain under#21 Remarks) I
FROM To DESCRIPTION color,hardness,soil/roek in size,etc
ft. l p ft �t►a ti
4.Date Well(s)Completed: Well ID# D R' (p b ft t- b: t
5a.Well Location: GD ft G sr ft e-r,�
Facility/Owner Name a Facility ID#(if applicable) h' R
l b$a (_ra55,_1 eek kr'y+.( Iky- ft. ft. 9m,y✓r�
Physical Address,City,and Zip y1D u ft. ft.
`+ d
/ 1 21.11EMARKS
YarSy !-1'�- �r,Les�lrt
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:
N �� ZS� SI. 7GY'� W
� " � IL6.Is(are)the well(s)�ermanent or Temporary Si o Ce r r well ontractor 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: DYes or Meo 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: 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 if different(example-3@200'andd_1@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: lQ (in.) 24b.For Infection 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: kesa- KAI.r construction to the following:
(Le.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) 10 Method of test: c1%41.6, 24c.For Water SunDly&Infection Wells: In addition to sending the form to
pl the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:h+L'`70% 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 Water Resources Revised 2-22-2016