GW1-2021-07919_Well Construction - GW1_20211122

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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 I DESCRIPTION
"18-A W ft. IG ft. �K
,t it-
NC C�c
Well Contractor Certification Number 15.OUTER CASING for multi-cased'wens OR LINER' applicable)
t;
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS I MATERIAL
Company Name
D ft `I. /tS It.
1P ��
V(..16.INNER CASING OR TUBING: eothermal"closed-loo ,.;
2.Well Construction Permit#: f1-r(6`? FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. fL in.
3.Well Use(check well use): ft. fL in.
Water Supply Well: 17.'SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. % in.
Geothermal(Heating/Cooling Supply) URsidential Water Supply(single) it. ft. in.
7ndustrial/Commercial Residential Water Supply(shared)
18.GROUT
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: k. ft.
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19 SAND/GRAYEI;'PAGK ifs'"'licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. It.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal eaten Coohn Return) rJOther(explain under#21 Remarks) FROM To DESCRIPTION color,hardoess,soil/rock type,grain size,etc.
15 fL
4.Date Well(s)Completed: 11-13^_71 Well ID# It. 43 It-
t 1,11 ,
Sa.Well Location: ft. ft. p� y
1A 1S:fed fL ft. Ao 6 F
Facility/Ovger Name Facility ID#(if applicable) ft. It.
231 (,Pes Cgove 1Rt5 „4i"lec C'.W ,Uc ,;, _q4q fL ft.
Physical Address,City,and Zip or ft. fL
21.REMARKS
[lYfYi a
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) �7 22.Certification:
9
950 Ll ®.511 N 99� a5t 55.ail W
6.Is(are)the well(s) ermanent or E3Temporary Si cure ofttertified Well ontractor 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 dNNo with 1 SA 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 ofthis 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: �1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 00 24a. For Ail Wells: Submit this.form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2Q100� construction to the following:
10.Static water level below top of casing: 40 (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
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: UCtl kS construction to the following:
(Le.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:(Alrh dr Ttih2 24c.For Water Supply&Iniection 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: HT"70% Amount: I&W 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