GW1-2021-07581_Well Construction - GW1_20210903

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Gary Thompson ai 1!C.® 14.WATER ZONES
Well Contractor Name
T<-1�^ FROM TO DESCRIPTION
9
4418-A iv►^
,
NC Well Contractor Certification Number C` t� U OUTER CASING for muldtased wells OR LINER if a 6cable
Agdua Drill, Inc. S `o�sslr9 FROM O DIAMETER THICKNESS MATERIAL
t: ft.
Company Name Watt—
*3 5-"e� oWR 16. C OR TUBING'(geothermal dosed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. n. i°•
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE T C ESS MATERIAL
Agricultural unicipal/Pubiic ft, ft.
in.
491
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial E3Residential Water Supply(shared)
18.GROUT
Irrl ation FROM TO M4TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring DRecovery
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 [3Stormwater Drainage ft.
fL
Experimental Technology Subsidence Control ft. it.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG'attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock rain size,etc.)
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks '
3cos
4.Date Weil(s)Completed: ����— '` Well ID# ft. ft
Sa.Well Location: ft, ft.
,i ' (/!
rIl ] 4Jr
Facility/Owner tame ,� n e Facility ID#(if applicable)
ILW��pei L �Sbi.J OA 3n,.uIriCYCt�h�{.�-,©�l. ft. ft.
Physical A`dddress,City,lmd Zip ft. ft.
�b 21.REMARKS
County Parcel Identification No.(PIN) SA kf— ���' �� �./" LkAN5
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: A20 L >
(if well field,one lat/long is sufficient) 22.Certification:
60
6.Is(are)the well(s) ermanent or 13Temporary SignaYureof rti ed Wel n1!mctor 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 or oNo 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 surface: ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2@100D cons 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 Iniecdon 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: r4hry 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 t�m' 24a For Water Supply&Injection 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: Amount: b 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