GW1-2021-04301_Well Construction - GW1_20210430

rm
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.1411.Contractor Information:
a
Gary Thompson 14.WATER ZONES'
Well Contractgr Name FROM TO DESCRIPTION
4418-A % ft. -7 ft.
� ft. .� ft.
NC Well Contractor Certification Number 15.OUTER CASING for.multi-cased wells OR LINER if a licable
Aqua Drill, Inc. FROM TO DIAMETER' THICKNESS MATERIAL
ft � ft �, to s/y o (Spy V,
Company Name
, . ` 16.INNER CASING OR TUBING-geothermal closed-loop)
2.Well Construction Permit#: W �� - \ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft It. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
� FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agri cultural hT unicipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) EfResidential Water Supply(single) ft. ft. in:
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
IITI atlon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a ft �> ft. jd 6 ur C 5 4 Tt
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL'PACK'if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ©IStormwater Drainage ft. fa
Experimental Technology ]Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,gnin size,eta
O ft, kb ft cr-d.
4.Date Well(s)Completed: 5 -Z l Well ID# I&P ft. '1 ft. t
5a.Well Location: 17 ft. ft G �`A'X
K,r+ 1i:C fL ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
n 1 ft. ft.
101S ��:S�Ati+ll Y�.�:`�S1b�ri7 WC ZZ'1.��
Physical Address,City,and Zip ft. ft. 5-1 U
c 21.REMARKS
County Parcel Identification No.(PIN)
r,l
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification
N �S6 6<4, , (S t W
6.Is(are)the well(s) Permanent or OTemporary
Signa�CerttSed tor 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: ®Yes orMKO00"
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 I 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: �S (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@200'and 2@100') construction to the following:
10.Static water level below top of casing: �-5 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (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: M'lu r�j >4 t ✓ 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: I 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �O Method of test: C41rLki ` 24c.For Water Supply&Injection Wells: In addition to sending the form to
/ 1 o J the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: )`16bl� Amount: !L / 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