GW1-2021-07543_Well Construction - GW1_20210903

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Gary W. Thompson 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4418-A ����1 q ft. lql ft Q
202t 90(4 fL f`_ GWA
NC Well Contactor Certification Number �( 3 15.OUTER CASING for multi-cased"wells OltLINER'if a" licable
Aqua Drill, Inc. SEP "M sgsStn9016A FROM TO DIAMETER THICKNESS MATERIAL
Company Name '�j
n 6 IL
1,95 ft-
t in 21 C
(� tY0 , On 16.INNER CASING OR TusING eothermal dosed-l6o`
2.Well Construction Permit#: e�?1\I LJT ea-onn �toM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft r°'
3.Well Use(check well use): ft. f1 in.
W Well: 17.SCREEN
ater Supply FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E]MunicipaVPublic U ft. ft. in.
Geothermal(Heating/Cooling Supply) &Residential Water Supply(single) ft. & in,
Industrial/Commercial 13Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO: MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a ft aq ft ajne4
Monitoring pRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge E3Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage & ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20>DRILLING,LOG attach additional sheers if necessary)
Geothermal(Heatin Cooling Return) MOther(explain under#21 Remarks t
TO DESCRnMON color,hardness,soiurock a in sae,et�ft.
4.Date Well(s)Completed: •a, Well ID# yo
ft Sa.Well Location: w t
[nrollna f%<U4�6M V40M h ft. l
Facility/Owner Name Facility ID#(if applicable) 1z it ft
G10u� Jl3 ChusrYL5 c&, 6f=nS ,LX M955_ ft. ft
Physical Address,City,and Zip ft ft
r,-;Ina 1 21.REMARKS
County C (YJ Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: in Unit
(ifwell field,one lat/long is sufficient) 22.Certification: © , DWR Section
3LO 1U' OU.'7o7G'I N �9° 4�t ICI. S� W
6.Is(are)the well(s) ermanent or Temporary Signature of 'ertifted Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or dNo with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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 surface: 3 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 1@100') construction to the following:
10.Static water level below top of casing: pq (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
� ,{1 _ r _N above,also submit one copy of this form within 30 days of completion of well
�,
12.Well construction method: ' 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: CfX��lone 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: HM 7001a Amount: lf,#-t completion of well construction t4 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