GW1-2021-00128_Well Construction - GW1_20211213

Pr(nt Form.
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
4418-A 'Ql� yft�ttie'�
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for molHeased wells OR LINER if a flcable
Aqua Drill, Inc. FROM 70 DIAMETER THICKNESSI MATERIAL.
0ft. qD ft. in 5 OD. `
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: 41W Li11i L,0d 1 FROM TO DIAMETER I 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. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSi2E THICKNESS MATERIAL
Agricultural []I umcipa/Public ft. ft. in.
:)Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft In.
IndustrialtCommereial DResidential Water Supply(shared) 1&GROUT
nlrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
No Supply Well: ft. .•
Monitoring Recovery ft. ft
Injection Well:
Aquifer Recharge []Groundwater Remediation ft. ft.
Aquifer Storage and Recovery Salini Barrier 19.SAND/GRAVEL PACK if applicable)
if S
q g ry tY FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ]Stormwater Drainage ft, ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cool' Return) M. Other(explain under#21 Remarks) FROM I TO DESCRIPTION(color,hardness•soilfmck %grain size,etc.
o ft. ft.
ID 4.Date Well(s)Completed: II-1 •�i Well # ft. l " ft.
So.Well Location: ya ft' '� ft.
f4-
/ ft. ft.
[Ltt'e2�:FiGI tfIiSJIat36Y1Fj cam} Dl1P1.4147t;;�
Facility/Owner Name Q Facility ID#(if applicable) ft. ft.
511194LI k1t-&Q iAi::YT. �czri�nr�} 7 1� ft. ft.
Physical Address,City,and Zip 0 ft. ft.
AIC1SrY1t1CQ 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 70
21
(if well field,one lattlong is sufficient) 22.Certification:
N ! i� n�©i �ti W !
6.Is(are)the well(s)EdPermanent or []Temporary Signature of Certified Well Contractor Date
By signing this forme.I hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or No with 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that
If this is a repair,fill out knower 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
constriction,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:_ .�'S ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@1001 construction to the following.
10.Static water level below top of casing: J0 (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: G (in.) 24b.For Iniection Wells: in addition to sending the form to the address in 24a
n s�iy above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: C^ 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: bA&4 1rt►e 24c.For Water Supply&Injection 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: '760ict Amount: 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