GW1-2021-06159_Well Construction - GW1_20211025

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Contractor Information:
Gary Thompson 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4418-A ft. 16,7
ft. j'l
1 ft. 'G ft I
NC Well Contractor Certification Number 15.OUTER CASTING for multi-cased we0s OR LINERi if a livable'
Aqua Drill, Inc. FROM TO DIAMETER THICKNEss MATFRrwr.
/\ ft. 55 It. in. if
Company Name V
t' 116.INNER CASING OR;TUBING" eothertoalel6sed-loo
2.Well Construction Permit#: n l���I(�u�bll 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. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipal/Public ft, ft, in.
Geothermal(Heating/Cooling Supply) aResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
38.GROUT
Irxi ation FROM TO MATERTAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0
ft. ft. 4
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.Aquifer Recharge 13Groundwater Remediation
19.SAND/GRAVEL PACK[if ii 'livable
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL I EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft
E (Heating/Cooling Return) lain under#21 Remarks
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG'attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soillruck in s' etc.
Geothermal
ft. ft
4.Date Well(s)Completed: 91 Well ID# ft. Q ft ,
5a.Well Location: ft, .5 & '
ft.
AlmmedA (1� ftm 4allries lac
Facility/Owner Name Facility ID#(if applicable) fL
34a LX }/O/' law�s uw,500I k)C ft. IL
Physical Address,City,and Zip ft. fL
21.REMARKS 4 RA _--n
County Parcel Identification No.(PIN) nvvRS@ctlon
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iattlong is sufficient) 1' ��ttr�yy - 22.Certification:
e'Sle rn1 1%'s11 N /�� 11�1 a j1 W ` t
6.Is(are
.)
✓t'hhe well(s)dPermanent or �T7emporary Signature of erti ed Well Con ctor �J 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: E)Yes or 13�No with 15A NCAC 01C.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#11 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: nnnnCC SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: _ _r, 5 00 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'and 2@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: (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: Ntf
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) Method of test: C jk&\ k�_1;q 24c.For Water SuDDIv&Iniection!Wells: In addition to sending the form to
v► ,` the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: ��N IOd1O Amount: L61- completion of well construction to the county health department of the county
where constructed.
Forth GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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