GW1-2021-07928_Well Construction - GW1_20211122

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Gary Thompson 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
k. 11 fL r
4418-A
k. fL
NC Well Contractor Certification Number 15.OUTER CASING:for multi-cased>wells OR LINER if a livable
Aqua Drill, Inc. FROM I To DIAMETER I THICKNESS MATERIAL
o ft. I QC/
ft. In.
Company Name :30
16.INNER CASING OR'TUBING eothermal closed-loo"0 '
2.Well Construction Permit#: u FROM TO DIAMETER THICKNESS. MATRRUL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft, ft. in.
3.Well Use(check well use): M ft. in.
Water Supply Well: 17-SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) aResidential Water Supply(single) ft. fL in.
Industrial/Commercial E3Residential Water Supply(shared)
18:GROUT
Irrl anon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 95 ft l NQA
,
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation 3
19.SAND/GRAVEL PACK%ifa'"-livable
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology E3 Subsidence Control ft. ft
Geothermal(Closed Loop) .Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal eatin Coolin Return Other(explain under#21 Remarks) FROM To DESCRIPTION color,Hardness soiUroek rain s' eta
ft. ft. j
4.Date Well(s)Completed: q-6• , Well ID#
5a.Well Location: T .____ff tt `j� ft. ft. r�
Nel i / JCC7T9' ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
l��ttlm'fed I lJatiV,er Go �4n1 /O5I ft. ft
Physical Address,City,and Zip IL
r -.1i_ 21.REMARKSZVI
County T Parcel Identification No.(PIN) GWR
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1NF0,RIM,ATI I
I
(if well field,one lattflong is sufficient) � n h 22.Certification:
8 t '1. O cq 11 N O(O• /(ntll) W
6.Is(are)the well(s) Permanent or 139remporary Signa re ofCtiMd Well 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: _ 13Yes or [BNo with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0100 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: 3 05 (ft) 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 2@100D construction 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 Infection Wells: In addition to sending the form to the address in 24a
t above,also submit one copy of this!,form within 30 days of completion of well
12.Well construction method: lk,.f 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 276994636
24e.For Water SUDDIV&Infection Wells: In addition to sending 13a.Yield(gpm) Method of test:�tdiS�f \:@nr?. g the form to
y the address(es) above, also submit!one copy of this form within 30 days of
13b.Disinfection type: 0to Amount: I�L 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