GW1-2021-07918_Well Construction - GW1_20211122

Print Form.
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Gary Thompson 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. IfL \ �(1
4418-A t'
ft. tt
NC Well Contractor Certification Number 15.OUTER CASING for multi cased:wells'OR LINER �f a' 6cable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
O ft. 2P_ ft in. 1
Company Name
pe� 16 INNER CASING OR TUBING "otherma4dosed
2.Well Construction Permit#: 1 J FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits f.e.UIC,County,State,Variance,etc.) ft, ft. In.
3.Well Use(check well use): ft. M in.
Water Supply Well: IISCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural �MunicipaVPublic {t, {(, in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. it.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge [3Groundwater Remediation
Aquifer Storage and Recovery ��'qg�Salini Barrier ,19 SAND/GRAVELiPAGK'ifa`"'tieable. _ $ �,
�y ty FROM TO MATERIAL _ EMPLACEMENT METHOD w
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. %
Geothermal(Closed Loop) Tracer DRILLING LOG attach addidonal sheets'if nec6Wt"
Geothermal(Heating/CoolingReturn Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sollfrocktym prain size,etc.
ft. ft.
4.Date Well(s)Completed:_t� Well ID# ft. tt
Sa.Well Location:
ft" , t
ft, ft.
(ItiukAn Mrk�;�P_ 9 � '&wa ft. ft.
Faci /Owner Name Facility ID#(if applicable)
ft, ft. ifb
Physical dress,Ci ,and Zip ft. %
1n5t.3e1� 21 REMARKS
County Parcel Identification No.(PIN) lt7` UVVR SEG TIu",'
I IV PROC�,4
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: S1r v l
(if well field,one lat/lonn�g its sufficient) n 22.Certification:
nn% N `MD �t1 10.9it
lk�l.O �� •'a$r—'��
6.Is(are)the wells)&Permanent or 13Temporary Signature of Certified We Contractor 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 E(No with 15A NCAC 02C.0100 or ISA 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 retard 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: e� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 05 (f0 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@20``0__'ame�nd 2@100) construction to the following:
10.Static water level below top of casing: I00 (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 Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
!,1 _t ,,� A`�, above,also submit one copy of this form within 30 days of completion of well
_L(�R
(Le.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13s.Yield m
(gP ) %f4 Method of test: _ ���'snP_ 24c.For Water Suooly&Injectioe Wells: in addition to sending the form to
vr� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTN lOald Amount: IGO, 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