GW1-2021-07982_Well Construction - GW1_20211122

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Gary Thompson 14.WATER ZONES'
Well Contractor Name FROM TO DESCRIPTION
4418-A NO/� f t 1 � It- (0
n/�A6 ft. Qy fL
d
NC Well Contractor Certification Number 15.OUTER CASING for multi-casedlwells ORI.INER ifa' licable
Aqua Drill, Inc. FROM To DIAMETER THICKNESS MATERIAL
ft. 1OC,' ft. In. TUC
Company Name ,
O� 16.INNER CASING OR SUBING eothermal klosed400
2.Well Construction Permit#: O FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. fL In.
Water Supply Well: 17:SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. % in.
Geothermal(Heating/Cooling Supply) IgResidential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared)
`-18:GROUT
Ir'1 atiom FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. , f
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL'PACK:"ifa"'ilcable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test ®IStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. fL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG,attach additional sheets[if necessa
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,soilfrock type,grain size,etc.
it. fL
4.Date Wells)Completed:w-ao-a� Well ID# ft. to
5a.Well Location: t ft. % A y
(ICtlAdn P& e- t'LOM6 00 ft. ftOnAe
Facili /Owner Name Facility ID#(if applicable) k' R- r r.
ft. tL
f wo we-law smim FA. k(AtaD�r 1: e, A)C_ a2-
Physical Address,City,and Zip ft. fL
t Pi
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
O .991 _fb 7 is
N lqr W.0 r W � 9-
6.Is(are)the well(s)EfPermanent or 131remporary Signature of Jertf6ed Well Co tractor 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 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 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: t2Q5 (ft-) 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@I00) construction to the following:
10.Static water level below top of casing: 50 (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: (0 (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: Are 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 27699-1636
13a.Yield(gpm) to Method of test: (Ak)dr Y the 24c.For Water Supply&Iniection Wells: In addition to sending the form to
!!''-f� � f the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: t l i H 7OOItZ Amount: (1dQL 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