GW1-2021-00249_Well Construction - GW1_20211213

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Gary Thompson 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
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4418-A tt. Y
NC Well Contractor Certification Number 184 ft. 190 ft 40 URK �k e-
15.OUTER CASING:for multi-casediwells AR LINER if,, licable
Aqua Drill, Inc. FROM To DIAMETER THICKNESS MATERIAL
fL in.
Company Name
16. A G:OR TUBING eothermal'closed-loo
2.Well Construction Permit#: Iw 1Abffl N6-©V:-?l 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 1
FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
Agricultural [3Municipal/Public ft, ft.
Geothermal(Heating/Cooling Supply) ffResidential Water Supply(single) ft.
Industrial/Commercial [3Residential Water Supply(shared) 18.GROUT
1 11ri ation FROM TO MATERIAL EMPLACEMENT METAOD&AMOUNT
Non-Water Supply Well: ft. fL
Monitoring 13Recovery ft. ft.
Injection Well: f
Aquifer Recharge Groundwater Remediation
19 SAND/G13AYEL PACK ifs 7lcable
Aquifer Storage and Recovery [ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. fL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional{sheets if necessary)
Geothermal (Heating/Cooling Return) MOther(explain under#21 Remarks) FROM ft. To fL DESCRIPTION(color,hardness,soillrock in e' etc
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4.Date Well(s)Completed: 11-17-A well ID# ft. fL
5a.Well Location: ft. ft
%,j 1111n1t3L.J f`. Xl
Facili /Owner Name Facility ID#(if applicable)
ft, It.
ft. t
ICY,, A)eW L,ebwan (ha�tY.11 ,o� `963sudielAiC 07390 " '
Physical Address,City,and Zip ft. ft
n ,. -2L REMARKS DEC
f1C&)"flg am
County G Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r` r'-'•..`'! '
(if well field,one lat/long is sufficient) 22.CJerrpdlieation: i r
6.Is(are)the well(s)6ermanent or OTemporary Signanre of& ed 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: lyYes or [3No with 15A NCAC 01C.0100 or 15A NCAC 01C.0100 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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: �l�I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: .916 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@100D construction to the following:
10.Static water level below top of casing: 40 (fL) 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 (1n•) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of thisiform within 30 days of completion of well
12.Well construction method: Arc 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) too Method of test: (Akb 4 tl,& 24c.For Water Sunnly&Iniection 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: HTH"VolO Amount: 160L 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