GW1-2021-07934_Well Construction - GW1_20211122

Print WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: Form
1.Well Contractor Information:
Gary Thompson IC WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4418-A ft ft. 4H �
ft. 1 ft-
NC Well Contractor Certification Number gog15.OUTER CASING'for multi-cased wells OR LIIVER if'a licsble
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft in. /.1,.0
Company Name % �V
1 16.INNER CASING',OR TUBING eothermal'closedaoo
2.Well Construction Permit#:, 21'04- 1,1014ft-0%0 5Q FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN ZE FROM TO DIAMETER !SLOT SI THICKNESS MATERIAL
Agricultural gi3yunicipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft, ft. in.
Industrial/Commercial Residential Water Supply(shared)
•18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring 13Recovery ft. ft.
Injection Well:
Aquifer Recharge 13Groundwater Remediation ft. ft.19.SAND/GRAVEL PACK if a "licable
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft
Experimental Technology ®I Subsidence Control R. ft.
Geothermal(Closed Loop) 13Tracer 20:DRILLING LOG attach additionalisheets if necessa
Geothermal eatin Coolin Return) 130ther(explain under#21 Remarks) 1
FROM TO DESCRIPTION color,hardness,solttrock type,grain s' etc
ft. Q0 IL
nali
4.Date Well(s)Completed: 1 Well ID# ft. ft'
5a.Well Location: O ft, ft. I
rt. fL .+
lotn S:fntnonS
Facility/Owner Name Facility ID#(if applicable) ft. f4
Physical A�ddre 11,City,and Zip ft. ft.
ylilkA(H 21 REMARKS
County Parcel Identification No.(PIN)
Gv#R S--'Cuoi
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
% a q' 35.1" N 7190 5i6' 44.a" W , (7Kbn-,,r.4.y 11
6.Is(are)the well(s)efPermanent or 13Temporary Signature of CeikifiecT 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 ordNo with 1 SA NCAC 02C.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: y.?5 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 3 (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
' , _q xx above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: riC}tUS 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: Cnk�1 Jr T:ne 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: 10010 Amount: 601- 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