GW1-2021-07959_Well Construction - GW1_20210809

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Gary Thompson 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft �(_t ft. ,)
4418-A ft D5 ft 4
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased Wells Oa LINER if a licable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
QfL ft. C I in.
Company Name
!'� 16.INNER CASING ORTUBING geothermal closed-loop)
2.Well Construction Permit#:L969 710S-0all FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft It. in.
3.Well Use(check well use): ft It.
in.
Water Supply 17.SCREEN
pp y Well: FROM TO DIAMETER ' SLOT SIZE THICKNESS MATERIAL
:-,')Agricultural unicipaUPublic 0 ft ft
C Geothermal(Heating/Cooling Supply) IgResidential Water Supply(single) ft. ft, in.
i
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft
Monitoring [Recovery fL fL
Injection Well:
ft ft
` Aquifer Recharge []Groundwater Remediation
19.SAND/GRAVEL PACK'if a Gca61e
_:]Aquifer Storage and Recovery ©)Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft ft
Experimental Technology [I Subsidence Control ft ft.
Geothermal(Closed Loop) '[IJ Tracer 20.DRILLING LOG'attach additional sheets if necessary)'
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain Size,etc
It.
ft
Ckcri
4.Date Well(s)Completed.A 127-.?1 Well ID# ft
5a.Well Location: ft ft
ft ft
Teem S;mm�>Ir
Facility/Owner Name Facility ID#(if applicable) qn ft ft
\ It. ft n
P sical Address,019,and Zip ft ft
21.REMARKS 11�
�COPJ�V�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/lon�gr�is sufficient) M 22.Certification:
JU ;.71�59" N A �t iZ.-i�l4,t W
6.Is(are)the well(s)[dPermanent or [Temporary SigWaturc Certified 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: Dyes or EdNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fell 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 wellldetails:
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-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: ]l�� (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@100') construction to the following:
10.Static water level below top of casing: ufl (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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: ky ->h(31+(M construction to the following:
(i.e.auger,rotary,cable,direct pushy 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: lxmS\ �� 24c. For Water Suppiv&Iniectio 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: NTH 'T2�10 Amount: Kj�o7_ completion of well construction to the county health department of the county
where constructed.
Form GW-I Nortb Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016