GW1-2021-06148_Well Construction - GW1_20211025

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only: Print Form
I.Well Contractor Information:
Gary Thompson
14.WATER ZONES '
Well Contractor Name FROM TO DESCRIPTION
4418-A i e. o rt - K
NC Well Contractor Certification Number fL
Aqua Drill, Inc. R.OUTER CASING foi muftitayed wails OR LDYER f a" liable
FROM TO DIAMETER THICKNESS MATERIAL .
Company Name a ft. 51 ft. In.
2.Well Construction Permit#: N LJ Nc`�� u-QO 16.INNER:CASING OR TUBING "eothermiil dosed-loo
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable it-ell construction permits(r.e.UIC,Cou uv,State.Variance,etc.) ft. ft In.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
Agricultural unicipal/Public FROM TO DIAMETER EOTSin THICKNESS MATERIAL
_ �
Geothermal(Heating/Cooling Supply) &R ft, ft in.
esidential Water Supply(single)
ft. ft in.
Industrial/Commercial IIResidential Water Supply(shared)
Irri ation 18.GROUT
Non-Water Supply Well:
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
M ft. ft
onitoring Recovery
Injection Well: k' ft
Aquifer Recharge Groundwater Remediation ft• ft
Aquifer Storage and Recovery OSalinity Barrier ,19.SAND/GRAVEL PACK if.a liaable
FROM TO MATERIAL EMPLACEMENT METHOD
LGeOthermal
er Test oStormwater Drainage ft. ft.
mental Technology Subsidence Control ft. ft.
ermal(Closed Loop) Tracer 20.DRILLING LOGattach additional beets if necess(Heatin Cooling Retum) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness soiUrork a rain arse eta)
ft. ft
4.Date Well(s)Completed: l0.7I Well ID# 2pft. ft.
Sppa..—Well
Location: ft. ft. ,
J�111 �>CS�AtYI E�Bfilt°S Tn!' ft. ft
Facility/Owner Name Facility ID#(ifapplicable) ft• tt
M L
Physical Address,City,and Zip ft ft
21.REMARKS r III
County Identification No.(PIN) 9P+1o[r'.3PAIR i rpr1101
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilong is sufficient)
22.Certification:
.7�' 149A-F N �9a �i8' g2.6 ti W
O-MW-11 6.Is(are)thewell(s)dIPermanent or Temporary Signature o�rti Con ctor Date
7.Is this a repair to an existing well: QYes or WNo with i15A NCAC 02C.0100 or/SAgning this form,I herebytNCAC 02C t 0200)Well Construction Standards and fy that the well(s ,,as(were)constructed in that a
If this is a repair,fill out knoim well construction information and explain the nature of the cop)'of this record has been provided to the well owner.
repair under#21 rentarkr 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:
n SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ,�/ (ft-)
For multiple wells list all depths ifdiQerent(example-3@200'and 2@100� 248. FOr All Wells: Submit this form within 30 days of completion of well
►1 construction to the following:
/f water lavel is above casing,tore
f Static water level below top of casing:_ �4 (ft.) Division of Water Resources,Information Processing Unit,
"+"
11.Borehole diameter.
1617 Mail Service Center,Raleigh,NC 27699-1617
(in.)
24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
EDIsinfection
UPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
�,( Method of test: 1� t
de�.li�L 24c.For Water Sunnly&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
type:_IA�N 26 Amount: �{Dt� completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016