GW1-2021-00194_Well Construction - GW1_20211213

TIni Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
i
1.Well Contractor Information:
Gary Thompson 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
' ft
4418-A
NC Well Contractor Certification Number 64
r r
15.OUTER CASING for multi-cased weus'OR:LINER if a ucable
Aqua Drill, Inc. FROM TO DIAMETER I THICKNESS MATERIAL
k. ft in.
Company Name o
,n '16.INNER CASING OR TUBING(g eothermal'elosed-loo
2.Well Construction Permit#: 19-OG-( oyA Yl- d3571 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) k• tt lo.
3.Well Use(check well use): k. ft. I in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural P unicipaL/Public k. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft Y
ruch
Monitoring Recovery ft. ft
Injection Well: k. ft
Aquifer Recharge 13Groundwater Remediation
19.SAND/GRAVEL:PACK ifs "ucable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage k. ft
Experimental Technology Subsidence Control k. ft.
Geothermal(Closed Loop) Tracer 20 DRILLING LOG attach additional'sheets if necessary)
Geothermal (Heating/Cooling Return) 00thcr(explain under#21 Remarks FROM TO DESCRIPTION color,hardy soil/rock type,Min size,etc
k. ft
Ciao
4.Date Well(s)Completed: I I-q-a1 well ID# ft. ft
5ac.,Well Location: k' k' C
S4tue MlAfl'Idfl 50
ft'
ttIlue ,
Facility/Owner Name Facility ID#(if applicable) k. ft
010 14arnill Imo, 5flSnd_2&=1 AIIC 97a89 ft. fr. —�
Physical Address,Cit,and Zip ft. ft
-c ItOfa 21.REMARKS
c W 02�
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: f I
350 5q' N 79° 55' 5.3" w
6.Is(are)the well(s)dPermanent or Temporary Signatu of C 'fie 'Well C ttacror 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: [3Yes or 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: CC SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: CI? (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: 46 00 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: f4 (in.) 24b.For Iniection Wells: in addition to sending the form to the address in 24a
n '.�U �i6 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: KOt
(i.e.auger,rotary,cable,direct push,etc.) Construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) K7 Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit'lone copy of this form within 30 days of
13b.Disinfection type: HTW '760/o Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016