GW1-2021-06157_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
� rt
4418-A ft. 1
Ao ft. i th hl
NC Well Contractor Certification Number 15.OUTER CASING for multi-cssed±ells OR LINE a licable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS I MATERIAL
Company Name
Q ft. ft. in. ' I tpkx
16.INNER:CASING OR TUBING" eothermal closed-loop)
2.Well Construction Permit#: ,dl.:� � i�)� 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. ft. in.
Water Supply Well:. 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) WResidential Water Supply(single) ft, ft. in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19 SAND/GRAVELPAGK'if A"`llceble
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 1IStormwater Drainage ft, ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG'attach additional sheets if necessary)
Geothermal (Heating/Cooling Retum) r3Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiliroek type,griti,sh,etc
Q ft. Q fL
4.Date Weil(s)Completed:J&?-,2k Well ID# R. ft.
Int
Sa.�Wel►Locati�on 5
n: 35
ft. ft.
A(1�'Wki "l11SgIft fa ft ,
FacilityFacifi y/�e Facility ID#(if applicable) ft. ft.
100 M:armt Srx',nms lid. &Xsonn JJ(Q�C r ft. ft.
Physical Address,City,and Zip k. ft.
21.REMARKS ornce55
.
County Parcel Identification No.(PIN) 1� R$BGl!011
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
2LI*,2V 4y.311 N `190 .58' W" W _
6.Is(are)the well(s)E(Permanent or TempoWNo
Signature of erti red Well ntrac�for/ 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: [3Yes or 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 surfacer (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 t@200'and 2Qa 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: (a (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: I�dlt4CCP Nix 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:P Y.mt. 24c.For Water Supply&Infection 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: MTH 'OIp Amount: RZOL 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