GW1-2021-03916_Well Construction - GW1_20210823

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WELL CONSTRUCTION RECORD(GW-1) %r For Internal Use Only:
1.Well Contractor Information:
Gary Thompson la. TER ZO1vES
Well Contractor Name >F OM TO DESCRIPTION
`1t rrJ�y� e. ft fir, G jo l
4418-A P - S:`•^ ft. ft.
NC Well Contractor Certification Number D
15.OUTER CASING for multi caseH wells SS OR LINER if a livable
Aqua Drill, Inc. ���` O FROm TO DIAMETER THICKNE MATERIAL
Company Name ft. [.{S'- ft z157 in.
���� �,b� _� '16.INNER CASING:Olt TUBING: 'eothermal'elosed-loo
2.Well Construction Permit#: _)— FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UI ,County,State,Variance,etc.) fL ft in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Q icipal/Public ft. ft in.
ft,Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft in.
Industrial/Commercial Residential Water Supply(shared)
a18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft' 32) ft' e� ,el.t
Monitoring Recovery ft. ft
Injection Well: ft t f
Aquifer Recharge Groundwater Remediation ;19:SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) OTracer 20:DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soillrock type,grain size,etc.)
ft. I ft
4.Date Well(s)Completed: "�:� Well ID# ft. Y� ft e J
5a.Well Location: dle ft. ft rsm N t
1/Ste, H ft (,l� ry
Facility/Owner TAme Facility 110(if applicable) ft. fL
��.1'VtY l\1 /ill! l��>'� /'✓L 27 ZS/� ft. ft
Physical Address,City,and Zip -- ft ft
F�CL'�il+rS A0— 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1aUlong is sufficient) 22.Mon:
166�i �2'a_ '"IN N 77� E/� � hid a D _5 W
6.Is(are)lire well(s) ermanent or Temporary Sigueture ofJ:V C 'fled Well ntractor 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: Oyes or 12y< with 15A NCAC 02C.0100 or ISA NCAC 02C.0100 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 ofthis 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' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J (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@I00) construction to the following:
10.Static water level below top of casing: 91 (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
12.Well construction method: r't4t' above,also submit one copy of tliis form within 30 days of completion of well
1�N a• r 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 276994636
13a.Yield(gpm) �',Q Method of test: eh L"�,6wvr__ 24c.For Water Suonly At 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: tD Amount: 14 �/Z 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