GW1-2021-06156_Well Construction - GW1_20211025

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Gary Thompson 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft.
4418-A 1 N19
ft
3 ft. o945 ft- x
NC Well Contractor Certification Number 15.OUTER CASING for multi-casedwells OR LINER if a livable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Q ft. � ft. in. TVC
Company Name "
i1'-�� t1 16.INNER CASING OR:TUBING eothermal dosed400
2.Well Construction Permit#:L MJ _,,�n -()Iq FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(.e.UIC,County,State,Variance,etc.) ft. ft io.
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) ffResidential Water Supply(single) ft. ft. in,
Industrial/Commercial DResidential Water Supply(shared)
18:GROUT
Jb
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Weil: ftJmb�02
ft i
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
.:19.:SAND/GRAVEL PACK"if iNilicable .i
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
NExperimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additionid sheets if necessary)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soil/fuck tyM Wain size,etc
© ft. ft
4.Date Well(s)Completed: 10-(a-Q1 well ID# ft. go It. ,`
5a.Well Location: Q ft, %70 tt ,
Facility/Owner Name Facility ID#(if applicable) ft. fL
�g!� n ` `� � ft. ft.
frSY uoec 1 At AaC'.snnt ft. %IL, 2OZ�
Physical Address,City,and Zip
21.REMARKS'
Tr
County Parcel Identification No.(PiN) infdrrnifion proc@SSIng
ec�..
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: p�R
011
(if well field,one lat/long is sufficient) p 22.Certification:
3c° la
Z O9tt N 7qO US' t0ji t W J1 1�Je•`��
6.Is(are)the well(s) ermanent or OTemporary S ( laft offC\ ified Well Con ctor l3ate
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: 13Yes or dNNo with 15A NCAC 02C.0100 or I5A NCAC 01C.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 ofthis 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: //yy.� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 0%5 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3@200'and 1@100) construction to the following:
10.Static water level below top of casing: UO (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: On-) 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: 13ky A'& construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) ff
Division of Water Resources,Undergronnd Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
l
13a.Yield(gpm) Method of test: C k)r% 4'[ate 24c.For Water Supply&Iniectionn 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:gJlA NI{'FlO 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